Provider Demographics
NPI:1093310591
Name:LANGE, BRANDON MICHAEL
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:LANGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BRANDON LANGE 3285 122ND AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010
Mailing Address - Country:US
Mailing Address - Phone:269-673-6671
Mailing Address - Fax:
Practice Address - Street 1:677 ELY ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1541
Practice Address - Country:US
Practice Address - Phone:269-270-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007638225XM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health