Provider Demographics
NPI:1982198826
Name:LANG, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LANG
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 1:600 WOODDALE BLVD APT 270
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-2990
Mailing Address - Country:US
Mailing Address - Phone:832-768-0227
Mailing Address - Fax:
Practice Address - Street 1:600 WOODDALE BLVD APT 270
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-2990
Practice Address - Country:US
Practice Address - Phone:832-768-0227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA00000Medicaid