Provider Demographics
NPI:1104046416
Name:LANGSTON, SIDNEY WHITLEY (PHD, DMIN, RN)
Entity type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:WHITLEY
Last Name:LANGSTON
Suffix:
Gender:F
Credentials:PHD, DMIN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:116 S. PROVIDENCE ST.
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-1044
Mailing Address - Country:US
Mailing Address - Phone:704-843-4818
Mailing Address - Fax:704-843-5111
Practice Address - Street 1:116 S. PROVIDENCE ST.
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-1044
Practice Address - Country:US
Practice Address - Phone:704-843-4818
Practice Address - Fax:704-843-5111
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC076547101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC50913OtherINSURANCE PROVIDER NUMBER