Healthcare Provider Details

I. General information

NPI: 1699984815
Provider Name (Legal Business Name): TERA JAMES LANGSTON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 FORTUNE BLVD
SHILOH IL
62269-7358
US

IV. Provider business mailing address

1001 LUNA CIR NW
ALBUQUERQUE NM
87102-1973
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-6988
  • Fax:
Mailing address:
  • Phone: 505-266-0388
  • Fax: 866-318-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7811
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1357
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: