Provider Demographics
NPI:1942744875
Name:LANGE, SAMANTHA (LMT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11421 OLD GLENN HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7783
Mailing Address - Country:US
Mailing Address - Phone:907-622-2500
Mailing Address - Fax:907-694-2289
Practice Address - Street 1:11421 OLD GLENN HWY STE 101
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7783
Practice Address - Country:US
Practice Address - Phone:907-622-2500
Practice Address - Fax:907-694-2289
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101890174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK101890OtherALASKA STATE MASSAGE THERAPY LICSENSE