Provider Demographics
NPI:1366004152
Name:LANGENDORF, COURTNEY JOY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JOY
Last Name:LANGENDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5528 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:NEW LISBON
Mailing Address - State:WI
Mailing Address - Zip Code:53950-9034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W5528 N SHORE DR
Practice Address - Street 2:
Practice Address - City:NEW LISBON
Practice Address - State:WI
Practice Address - Zip Code:53950-9034
Practice Address - Country:US
Practice Address - Phone:608-547-1518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
WI5506-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant