Provider Demographics
NPI:1275043721
Name:LANGLEY, GEORGETTA LYNN (CADC, ICADC)
Entity Type:Individual
Prefix:MS
First Name:GEORGETTA
Middle Name:LYNN
Last Name:LANGLEY
Suffix:
Gender:F
Credentials:CADC, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12506 FORTS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39562-6510
Mailing Address - Country:US
Mailing Address - Phone:251-377-3979
Mailing Address - Fax:
Practice Address - Street 1:7400 FOUNTAINBLEAU RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-8473
Practice Address - Country:US
Practice Address - Phone:251-377-3979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAD10-014L171M00000X, 251B00000X, 251S00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health