Provider Demographics
NPI:1659727659
Name:LANGE, MARY (LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 UNDERWOOD LN NW
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-1012
Mailing Address - Country:US
Mailing Address - Phone:507-213-4400
Mailing Address - Fax:
Practice Address - Street 1:521 UNDERWOOD LN NW
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-1012
Practice Address - Country:US
Practice Address - Phone:507-213-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN131621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical