Basic Information
| Provider Information | |||||||||
| NPI: | 1689882912 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANG | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MELANIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2168 BUNTS RD | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162883674 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4511 ROCKSIDE RD SUITE #330 | ||||||||
| Address2: | SUPPLEMENTAL HEALTH CARE | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169010400 | ||||||||
| FaxNumber: | 2169010401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 5565 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.