Provider Demographics
NPI:1427105535
Name:LANGE, SUSAN MARIE (OTRL)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:LANGE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3219 LARRABEE DR
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4216
Mailing Address - Country:US
Mailing Address - Phone:630-208-7141
Mailing Address - Fax:
Practice Address - Street 1:525 TYLER RD STE Q1
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-3360
Practice Address - Country:US
Practice Address - Phone:630-444-0077
Practice Address - Fax:630-444-0078
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.002677225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics