Provider Demographics
NPI:1790083004
Name:LANGSTON, DANA DERUSSY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:DERUSSY
Last Name:LANGSTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 LYNN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-6755
Mailing Address - Country:US
Mailing Address - Phone:919-627-4629
Mailing Address - Fax:
Practice Address - Street 1:2435 LYNN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-6755
Practice Address - Country:US
Practice Address - Phone:919-627-4629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4227103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical