Provider Demographics
NPI:1558081703
Name:LANG, MARYLOU IRWIN
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:IRWIN
Last Name:LANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 SW GREENWOOD WAY APT B
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-4633
Mailing Address - Country:US
Mailing Address - Phone:561-693-4021
Mailing Address - Fax:
Practice Address - Street 1:3930 SW GREENWOOD WAY APT B
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-4633
Practice Address - Country:US
Practice Address - Phone:561-693-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW49221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical