Basic Information
Provider Information | |||||||||
NPI: | 1710255716 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LANGHORST | ||||||||
FirstName: | ALYSE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, LLMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 428 | ||||||||
Address2: |   | ||||||||
City: | OWOSSO | ||||||||
State: | MI | ||||||||
PostalCode: | 488670428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897236791 | ||||||||
FaxNumber: | 9897255061 | ||||||||
Practice Location | |||||||||
Address1: | 1555 INDUSTRIAL DR | ||||||||
Address2: |   | ||||||||
City: | OWOSSO | ||||||||
State: | MI | ||||||||
PostalCode: | 488679775 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897236791 | ||||||||
FaxNumber: | 9897255061 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2011 | ||||||||
LastUpdateDate: | 04/23/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801093455 | MI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 750910401 | 01 | MI | BCCHRY | OTHER | 750910401 | 01 | MI | BCMI | OTHER | 018113 | 01 | MI | MIDWEST MEDICAID | OTHER | 00260F7 | 01 | MI | HAP | OTHER | 750910401 | 01 | MI | BCTR | OTHER | 7910401 | 01 | MI | BCBSFED | OTHER | XX19153 | 01 | MI | HEALTHPLUS | OTHER | 750910401 | 01 | MI | BCOOS | OTHER | 750910401 | 01 | MI | BCBS MEDICARE ADVANTAGE | OTHER |