MEDICARE: MARYANNA LANGE LCSW-R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	R058063-1	NY

General Provider Information

NPI Number	:	1437280021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYANNA LANGE LCSW-R

Provider Business Mailing Address
First Line	:	PO BOX 28
Second Line	:	43 BRIAR LANE
City	:	AU SABLE FORKS
State	:	NY
Zip	:	12912-0028
Country	:	US
Telephone Number	:	518-647-1239
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 US OVAL
Second Line	:	SUITE 201
City	:	PLATTSBURGH
State	:	NY
Zip	:	12903-5900
Country	:	US
Telephone Number	:	518-574-1360
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2007

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