Provider Demographics
NPI:1437280021
Name:LANGE, MARYANNA (LCSW-R)
Entity Type:Individual
Prefix:
First Name:MARYANNA
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:43 BRIAR LANE
Mailing Address - City:AU SABLE FORKS
Mailing Address - State:NY
Mailing Address - Zip Code:12912-0028
Mailing Address - Country:US
Mailing Address - Phone:518-647-1239
Mailing Address - Fax:
Practice Address - Street 1:22 US OVAL
Practice Address - Street 2:SUITE 201
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12903-5900
Practice Address - Country:US
Practice Address - Phone:518-574-1360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR058063-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health