Provider Demographics
NPI:1699241554
Name:LANGSTON, WILLIAM THOMAS (MED, ATC)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:THOMAS
Last Name:LANGSTON
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:MR
Other - First Name:BILLY
Other - Middle Name:
Other - Last Name:LANGSTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED, ATC
Mailing Address - Street 1:1402 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-6916
Mailing Address - Country:US
Mailing Address - Phone:217-244-7683
Mailing Address - Fax:
Practice Address - Street 1:1402 S 1ST ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-6916
Practice Address - Country:US
Practice Address - Phone:217-244-7683
Practice Address - Fax:217-333-6460
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0041662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer