Provider Demographics
NPI:1851383723
Name:LANGE, SHELLEY A (MS, PT)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:A
Last Name:LANGE
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:A
Other - Last Name:FEDERICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PT
Mailing Address - Street 1:PO BOX 2170
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-0480
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:720 12TH ST SE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-6708
Practice Address - Country:US
Practice Address - Phone:253-735-3606
Practice Address - Fax:253-351-9807
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA186057OtherDEPT OF LABOR & INDUSTRIE
WAB022OtherTRICARE
WA8938038OtherCRIME VICTIMS
WA8162FEOtherREGENCE BLUE SHIELD
WA8337396Medicaid
WA8337396Medicaid