Provider Demographics
NPI:1952891210
Name:LANGE, MCKENNA ANDERSEN
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:ANDERSEN
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 1:537 28TH AVE APT B
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-6242
Mailing Address - Country:US
Mailing Address - Phone:630-962-6744
Mailing Address - Fax:
Practice Address - Street 1:16000 BOTHELL EVERETT HWY
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1742
Practice Address - Country:US
Practice Address - Phone:425-357-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-12
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61160689101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health