Provider Demographics
NPI:1023798030
Name:LANGE, BROOKE EVELYN
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:EVELYN
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 1:403 S SANDIA ST
Mailing Address - Street 2:
Mailing Address - City:CONCORDIA
Mailing Address - State:MO
Mailing Address - Zip Code:64020-8354
Mailing Address - Country:US
Mailing Address - Phone:248-910-9126
Mailing Address - Fax:
Practice Address - Street 1:1209 HARNEY ST STE 105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-1838
Practice Address - Country:US
Practice Address - Phone:402-252-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician