Provider Demographics
NPI:1700059920
Name:LANGEVIN, PEGGY ANN (PT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:LANGEVIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 FREMONT ST
Mailing Address - Street 2:PO BOX 41
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201-1908
Mailing Address - Country:US
Mailing Address - Phone:920-487-5899
Mailing Address - Fax:
Practice Address - Street 1:1640 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3214
Practice Address - Country:US
Practice Address - Phone:920-499-5177
Practice Address - Fax:920-499-6035
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4645-024225100000X
ND176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4021700Medicaid