Healthcare Provider Details

I. General information

NPI: 1972420776
Provider Name (Legal Business Name): ELIZABETH LANGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 MCEWEN DR
NICEVILLE FL
32578-2730
US

IV. Provider business mailing address

306 MCEWEN DR
NICEVILLE FL
32578-2730
US

V. Phone/Fax

Practice location:
  • Phone: 850-517-6602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH25663
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: