Provider Demographics
NPI:1942723903
Name:LANGE, SHAWN ELISE I (COTA)
Entity Type:Individual
Prefix:MS
First Name:SHAWN
Middle Name:ELISE
Last Name:LANGE
Suffix:I
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 S RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-9505
Mailing Address - Country:US
Mailing Address - Phone:906-440-1440
Mailing Address - Fax:909-635-0970
Practice Address - Street 1:1011 MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-2650
Practice Address - Country:US
Practice Address - Phone:906-635-1518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL5201005798224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant