Healthcare Provider Details

I. General information

NPI: 1003247222
Provider Name (Legal Business Name): MARIBETH LANG M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2013
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N BROADWAY
INOLA OK
74036-9419
US

IV. Provider business mailing address

110 N BROADWAY
INOLA OK
74036-9419
US

V. Phone/Fax

Practice location:
  • Phone: 918-543-1000
  • Fax:
Mailing address:
  • Phone: 918-543-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12078159
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: