Provider Demographics
NPI:1558046656
Name:LANGE, ELISE (LAC)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4026 SAINT PETER ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SALADO
Mailing Address - State:TX
Mailing Address - Zip Code:76571-2149
Mailing Address - Country:US
Mailing Address - Phone:254-444-2236
Mailing Address - Fax:
Practice Address - Street 1:417 N MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:SALADO
Practice Address - State:TX
Practice Address - Zip Code:76571-6134
Practice Address - Country:US
Practice Address - Phone:254-444-2236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01323171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist