Provider Demographics
NPI:1265759872
Name:DE LANGE, SMADAR
Entity type:Individual
Prefix:
First Name:SMADAR
Middle Name:
Last Name:DE 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:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93024
Mailing Address - Country:US
Mailing Address - Phone:510-859-5975
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2120
Practice Address - Country:US
Practice Address - Phone:415-459-5999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health