Provider Demographics
NPI:1003949314
Name:LANG, ELLEN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:LANG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 PICKERING ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1516
Mailing Address - Country:US
Mailing Address - Phone:781-729-5645
Mailing Address - Fax:
Practice Address - Street 1:1301 CENTRE ST
Practice Address - Street 2:
Practice Address - City:NEWTON CENTER
Practice Address - State:MA
Practice Address - Zip Code:02459-2448
Practice Address - Country:US
Practice Address - Phone:617-964-6860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0467771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP10320OtherBCBS
MAP06242Medicare ID - Type Unspecified