Provider Demographics
NPI:1073862462
Name:LANGELLIER, DANE MICHAEL (ATC)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:MICHAEL
Last Name:LANGELLIER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:
Mailing Address - City:MARTINTON
Mailing Address - State:IL
Mailing Address - Zip Code:60951-0134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 MARION ST.
Practice Address - Street 2:
Practice Address - City:MARTINTON
Practice Address - State:IL
Practice Address - Zip Code:60951-0134
Practice Address - Country:US
Practice Address - Phone:815-383-5416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960033582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer