Provider Demographics
NPI:1376856377
Name:LANGE, TIFFANY MAE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:MAE
Last Name:LANGE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:TIFFANY
Other - Middle Name:MAE
Other - Last Name:LANGE - ALTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:300 25TH ST
Mailing Address - Street 2:APT 503
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451
Mailing Address - Country:US
Mailing Address - Phone:419-260-3919
Mailing Address - Fax:
Practice Address - Street 1:501 PRINCE GEORGE STREET
Practice Address - Street 2:SUITE 307
Practice Address - City:WILLIAMBURG
Practice Address - State:VA
Practice Address - Zip Code:23185
Practice Address - Country:US
Practice Address - Phone:757-903-2406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2022-01-11
Deactivation Date:2021-08-13
Deactivation Code:
Reactivation Date:2021-12-09
Provider Licenses
StateLicense IDTaxonomies
VA0810005526103TC0700X
VA0810005S26103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid