MEDICARE: KAITLYN LANGOLF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	5201009586	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17217	OTHER	CA	CA OT LICENSE

General Provider Information

NPI Number	:	1568026714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN LANGOLF

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	29600 S WIXOM RD
Second Line	:
City	:	WIXOM
State	:	MI
Zip	:	48393-3459
Country	:	US
Telephone Number	:	248-960-1600
Fax Number	:	248-960-9755

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2019
Last Update Date	:	10/29/2024

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Directions to “ KAITLYN LANGOLF ” Practice Location

Language	Start Address	Practice Location

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