Provider Demographics
NPI:1689096539
Name:LANGE, KEVIN DALE (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DALE
Last Name:LANGE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4208 RETAMA CIR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-2765
Mailing Address - Country:US
Mailing Address - Phone:361-582-0611
Mailing Address - Fax:361-582-0555
Practice Address - Street 1:4208 RETAMA CIR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-2765
Practice Address - Country:US
Practice Address - Phone:361-582-0611
Practice Address - Fax:361-582-0555
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1107324225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist