MEDICARE: TREVOR LANGSTON

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	103T00000X	Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20043265A	OTHER	IN	STATE LICENSE

General Provider Information

NPI Number	:	1992357859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TREVOR LANGSTON

Provider Business Mailing Address
First Line	:	4141 SHORE DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-2607
Country	:	US
Telephone Number	:	317-329-2525
Fax Number	:

Provider Business Practice Location Address
First Line	:	9531 VALPARAISO CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-1130
Country	:	US
Telephone Number	:	317-879-8940
Fax Number	:

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

Provider Enumeration Date	:	07/11/2019
Last Update Date	:	07/11/2019

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Directions to “ TREVOR LANGSTON ” Practice Location

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