Provider Demographics
NPI:1174610893
Name:LANGGUT, MARK BRIAN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:BRIAN
Last Name:LANGGUT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7401
Mailing Address - Country:US
Mailing Address - Phone:312-372-9780
Mailing Address - Fax:708-386-6251
Practice Address - Street 1:180 N MICHIGAN AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7401
Practice Address - Country:US
Practice Address - Phone:312-372-9780
Practice Address - Fax:708-386-6251
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-003953103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL572430Medicare ID - Type Unspecified