Provider Demographics
NPI:1760582464
Name:LANG, JOHN G (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:LANG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:721 BOND ST
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2729
Mailing Address - Country:US
Mailing Address - Phone:505-753-5811
Mailing Address - Fax:505-747-3210
Practice Address - Street 1:721 BOND ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2729
Practice Address - Country:US
Practice Address - Phone:505-753-5811
Practice Address - Fax:505-747-3210
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM318103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35068Medicaid