1790873974 NPI number — MS. SUSAN MARY LANGSTON MSW, LICSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790873974 NPI number — MS. SUSAN MARY LANGSTON MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANGSTON
Provider First Name:
SUSAN
Provider Middle Name:
MARY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790873974
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4037 22ND AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55407-3032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-729-3923
Provider Business Mailing Address Fax Number:
612-721-6022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 E 26TH ST
Provider Second Line Business Practice Location Address:
SUITE 302A
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55404-4359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-728-1032
Provider Business Practice Location Address Fax Number:
612-721-6022
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  10665 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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