Provider Demographics
NPI:1093837650
Name:LANGE, MARY A (LMT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:LANGE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:PO BOX 1853
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-1853
Mailing Address - Country:US
Mailing Address - Phone:386-439-6933
Mailing Address - Fax:386-439-6605
Practice Address - Street 1:210 MOODY BLVD
Practice Address - Street 2:
Practice Address - City:FLAGLER BEACH
Practice Address - State:FL
Practice Address - Zip Code:32136-3372
Practice Address - Country:US
Practice Address - Phone:386-439-6933
Practice Address - Fax:386-439-6605
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0012657225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist