Provider Demographics
NPI:1922816982
Name:LANGE, NICHOLAS EDWARD
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EDWARD
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 1:3301 COACHMAN RD APT 119
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2801
Mailing Address - Country:US
Mailing Address - Phone:612-799-3062
Mailing Address - Fax:
Practice Address - Street 1:1517 HIGHWAY 13 E
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2917
Practice Address - Country:US
Practice Address - Phone:612-756-9107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician