Basic Information
| Provider Information | |||||||||
| NPI: | 1790965663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANGE | ||||||||
| FirstName: | SHAWNA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEIN | ||||||||
| OtherFirstName: | SHAWNA | ||||||||
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| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 CROSS ST | ||||||||
| Address2: | |||||||||
| City: | BIG STONE CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572168237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055411140 | ||||||||
| FaxNumber: | 6055410109 | ||||||||
| Practice Location | |||||||||
| Address1: | 15620 EDGEWOOD DR STE 240 | ||||||||
| Address2: | |||||||||
| City: | BAXTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564016984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184547012 | ||||||||
| FaxNumber: | 2184547015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2007 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 102274 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 246567 | 01 | MN | MEDICARE | OTHER | 683227000 | 05 | MN | MEDICAID |