Provider Demographics
NPI:1821128711
Name:LANGE, CAROL GAY (MA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:GAY
Last Name:LANGE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 RAYMOND AVE
Mailing Address - Street 2:440
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1503
Mailing Address - Country:US
Mailing Address - Phone:651-642-9317
Mailing Address - Fax:
Practice Address - Street 1:821 RAYMOND AVE
Practice Address - Street 2:440
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1503
Practice Address - Country:US
Practice Address - Phone:651-642-9317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1530103T00000X
MN0689106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN28B54LAOtherBLUE CROSS BLUE SHIELD
MNHP15534OtherHEALTH PARTNERS