Provider Demographics
NPI:1255836169
Name:LANGE, TYLER ALEXIUS (PLPC)
Entity Type:Individual
Prefix:MS
First Name:TYLER
Middle Name:ALEXIUS
Last Name:LANGE
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62200 WESTEND BLVD APT 3105
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5635
Mailing Address - Country:US
Mailing Address - Phone:985-285-6096
Mailing Address - Fax:
Practice Address - Street 1:600 MARINERS PLAZA DR STE 603
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448
Practice Address - Country:US
Practice Address - Phone:985-465-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-24
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA009352933OtherBLUE CROSS BLUE SHIELD
LA009352933OtherHUMANA
LA009352933Medicaid
LA009352933OtherAETNA
LA009352933OtherCIGNA