Provider Demographics
NPI:1891917902
Name:LANGE, ROBERT (MOTR)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LANGE
Suffix:
Gender:M
Credentials:MOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E FULTON ST
Mailing Address - Street 2:APT 7
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1256
Mailing Address - Country:US
Mailing Address - Phone:414-313-0705
Mailing Address - Fax:
Practice Address - Street 1:1401 CHURCHILL ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-2027
Practice Address - Country:US
Practice Address - Phone:715-258-8131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5166-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41043600Medicaid