Provider Demographics
NPI:1154989176
Name:LANG, MARY BETH (SLP)
Entity type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:LANG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 S WHEATON AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-6485
Mailing Address - Country:US
Mailing Address - Phone:630-682-2050
Mailing Address - Fax:
Practice Address - Street 1:1125 S WHEATON AVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-6485
Practice Address - Country:US
Practice Address - Phone:630-682-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL654247OtherILLINOIS STATE TEACHING LICENSE