Provider Demographics
NPI:1083122147
Name:LANGE, NICHOLAS MARK (LPC/LMFT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MARK
Last Name:LANGE
Suffix:
Gender:M
Credentials:LPC/LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 OAK MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49333-8478
Mailing Address - Country:US
Mailing Address - Phone:231-286-2355
Mailing Address - Fax:
Practice Address - Street 1:6255 28TH ST. SE
Practice Address - Street 2:SUITE 3, OFFICES C&D
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:231-286-2355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101007011106H00000X
MI6401018602101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1715928Medicaid