Provider Demographics
NPI:1538831367
Name:LANGILLE, MARIE-SUSANNE (PTA)
Entity type:Individual
Prefix:
First Name:MARIE-SUSANNE
Middle Name:
Last Name:LANGILLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5660
Mailing Address - Country:US
Mailing Address - Phone:309-310-2701
Mailing Address - Fax:
Practice Address - Street 1:700 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3244
Practice Address - Country:US
Practice Address - Phone:309-310-2701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009370225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant