Provider Demographics
NPI:1831642719
Name:LANGE, ALYSE (LMSW, IBCLC)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:LMSW, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 GILKISON AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-8320
Mailing Address - Country:US
Mailing Address - Phone:269-615-0013
Mailing Address - Fax:
Practice Address - Street 1:6130 LOVERS LN
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-3026
Practice Address - Country:US
Practice Address - Phone:269-501-5017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011069251041C0700X
MIL-99168174N00000X
MI6801114754104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174N00000XOther Service ProvidersLactation Consultant, Non-RN