Basic Information
Provider Information | |||||||||
NPI: | 1528093523 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LANGELLE | ||||||||
FirstName: | CHARYLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THORNWELL | ||||||||
OtherFirstName: | CHARYLE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1015 S BROADWAY | ||||||||
Address2: | STE 18 | ||||||||
City: | MINOT | ||||||||
State: | ND | ||||||||
PostalCode: | 587014667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7018578500 | ||||||||
FaxNumber: | 7018578555 | ||||||||
Practice Location | |||||||||
Address1: | 1015 S BROADWAY | ||||||||
Address2: | STE 18 | ||||||||
City: | MINOT | ||||||||
State: | ND | ||||||||
PostalCode: | 587014667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7018578500 | ||||||||
FaxNumber: | 7018578555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 06/10/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 340 | ND | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | N19862 | 01 | ND | RR MEDICARE | OTHER | 054517 | 05 | ND |   | MEDICAID | 019862 | 01 | ND | BCBSND | OTHER |