Provider Demographics
NPI:1588857072
Name:LANGE, MICHAEL JOSEPH (MS, LP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:LANGE
Suffix:
Gender:M
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32298 STATE HIGHWAY 13
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:MN
Mailing Address - Zip Code:56069-4348
Mailing Address - Country:US
Mailing Address - Phone:507-933-5033
Mailing Address - Fax:
Practice Address - Street 1:1703 CSAH 15
Practice Address - Street 2:
Practice Address - City:ST. PETER
Practice Address - State:MN
Practice Address - Zip Code:56082
Practice Address - Country:US
Practice Address - Phone:507-933-5033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3351171M00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LP3351OtherPSYCHOLOGY LICENSE