Healthcare Provider Details

I. General information

NPI: 1396869038
Provider Name (Legal Business Name): ANNIE LANG LICENSED CLINICAL SO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S. MADISON AVENUE #310
PASADENA CA
91101
US

IV. Provider business mailing address

215 S. MADISON AVENUE #310
PASADENA CA
91101
US

V. Phone/Fax

Practice location:
  • Phone: 626-466-6271
  • Fax:
Mailing address:
  • Phone: 626-466-6271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number28207
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: