Provider Demographics
NPI:1942986146
Name:LANGE, AMANDA HOPE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:HOPE
Last Name:LANGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 MILLENNIUM XING
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8700
Mailing Address - Country:US
Mailing Address - Phone:260-444-8523
Mailing Address - Fax:
Practice Address - Street 1:1802 MILLENNIUM XING
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8700
Practice Address - Country:US
Practice Address - Phone:260-444-8523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39004550A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health