Provider Demographics
NPI:1386669026
Name:LANGE, ANGELIQUE Y (LMSW)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:Y
Last Name:LANGE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N ZIMMERMAN RD
Mailing Address - Street 2:
Mailing Address - City:BEULAH
Mailing Address - State:MI
Mailing Address - Zip Code:49617-9528
Mailing Address - Country:US
Mailing Address - Phone:313-595-4588
Mailing Address - Fax:231-882-4821
Practice Address - Street 1:402 N ZIMMERMAN RD
Practice Address - Street 2:
Practice Address - City:BEULAH
Practice Address - State:MI
Practice Address - Zip Code:49617-9528
Practice Address - Country:US
Practice Address - Phone:313-595-4588
Practice Address - Fax:313-231-8824
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010662781041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP43082Medicare UPIN
MIQ26426202Medicare ID - Type Unspecified