Healthcare Provider Details

I. General information

NPI: 1508121500
Provider Name (Legal Business Name): BETHANIE BROOKE LANGLOSS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 03/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 E CHURCH ST
MARSHALLTOWN IA
50158-2947
US

IV. Provider business mailing address

9943 HICKMAN RD SUITE 105
URBANDALE IA
50322-5304
US

V. Phone/Fax

Practice location:
  • Phone: 641-753-4021
  • Fax: 641-753-4025
Mailing address:
  • Phone: 515-248-1447
  • Fax: 515-248-1440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number008036
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: