Provider Demographics
NPI:1487664132
Name:LANGFORD, MARY LOU (PT)
Entity type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:LANGFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 LAFAYETTE DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1004
Mailing Address - Country:US
Mailing Address - Phone:505-259-2939
Mailing Address - Fax:
Practice Address - Street 1:4400 LEAD AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2844
Practice Address - Country:US
Practice Address - Phone:505-266-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM212225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26785OtherPRESBYTERIAN HEALTH PLAN
NMNM00Q054OtherBLUE CROSS BLUE SHIELD
NMB5268Medicaid