Provider Demographics
NPI:1235337528
Name:KELLY L. LANGE PSYCHOLOGY, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KELLY L. LANGE PSYCHOLOGY, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LANGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:858-218-4601
Mailing Address - Street 1:9606 TIERRA GRANDE ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-6501
Mailing Address - Country:US
Mailing Address - Phone:858-693-3113
Mailing Address - Fax:
Practice Address - Street 1:9606 TIERRA GRANDE ST
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-6501
Practice Address - Country:US
Practice Address - Phone:858-693-3113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21401103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty