Provider Demographics
NPI:1548399355
Name:DE LANGE, DAVID LEROY (MFT, PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEROY
Last Name:DE LANGE
Suffix:
Gender:M
Credentials:MFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5441
Mailing Address - Country:US
Mailing Address - Phone:310-822-8838
Mailing Address - Fax:310-577-6636
Practice Address - Street 1:4519 ADMIRALTY WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5441
Practice Address - Country:US
Practice Address - Phone:310-822-8838
Practice Address - Fax:310-577-6636
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT27767106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist