Provider Demographics
NPI:1649359894
Name:LANG, SHELLY ANN (OTR)
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:ANN
Last Name:LANG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:SHELLY
Other - Middle Name:ANN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:410 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KEWASKUM
Mailing Address - State:WI
Mailing Address - Zip Code:53040-8902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5595 COUNTY ROAD Z
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9224
Practice Address - Country:US
Practice Address - Phone:262-306-2100
Practice Address - Fax:262-306-2128
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3350026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40860100Medicaid