Provider Demographics
NPI:1790498319
Name:LANGE, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LANGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 PERRYSBURG HOLLAND RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9582
Mailing Address - Country:US
Mailing Address - Phone:419-693-1520
Mailing Address - Fax:
Practice Address - Street 1:U469 COUNTY ROAD 1D
Practice Address - Street 2:
Practice Address - City:LIBERTY CENTER
Practice Address - State:OH
Practice Address - Zip Code:43532-9598
Practice Address - Country:US
Practice Address - Phone:419-875-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator