Provider Demographics
NPI:1952811994
Name:LANG, JUSTINE ANNE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:ANNE
Last Name:LANG
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:ANNE
Other - Last Name:SCHELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31 SMITH LN
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3866
Mailing Address - Country:US
Mailing Address - Phone:631-588-9321
Mailing Address - Fax:
Practice Address - Street 1:35 YAPHANK MIDDLE ISLAND RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2369
Practice Address - Country:US
Practice Address - Phone:631-345-2783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027169235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05146396Medicaid