Provider Demographics
NPI:1871137984
Name:LANGENWALTER, THADDEUS LEE (PTA)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:LEE
Last Name:LANGENWALTER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7310 N 16TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5258
Mailing Address - Country:US
Mailing Address - Phone:602-535-8255
Mailing Address - Fax:
Practice Address - Street 1:7310 N 16TH ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5258
Practice Address - Country:US
Practice Address - Phone:602-535-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9066225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant