Basic Information
| Provider Information | |||||||||
| NPI: | 1568009959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANG | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | MICHELE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3009 CALHOUN RD | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486129775 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 449 QUARTER ST | ||||||||
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| City: | GLADWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486241918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894263430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2019 | ||||||||
| LastUpdateDate: | 12/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502003866 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.