Provider Demographics
NPI:1740215987
Name:LANGE, MARK WILLIAM (MED LMFT LMHC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:LANGE
Suffix:
Gender:M
Credentials:MED LMFT LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WRIGHT STREET
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:MA
Mailing Address - Zip Code:01069
Mailing Address - Country:US
Mailing Address - Phone:413-283-7651
Mailing Address - Fax:413-284-5117
Practice Address - Street 1:40 WRIGHT STREET
Practice Address - Street 2:WING MEMORIAL HOSPITAL GRISWOLD CENTER
Practice Address - City:PALMER
Practice Address - State:MA
Practice Address - Zip Code:01069
Practice Address - Country:US
Practice Address - Phone:413-284-5285
Practice Address - Fax:413-284-5384
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4668101YM0800X
MA1185106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist