Healthcare Provider Details

I. General information

NPI: 1194322826
Provider Name (Legal Business Name): DANIELLA RENEE LANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2883 EXECUTIVE PARK DR STE 102
WESTON FL
33331-3662
US

IV. Provider business mailing address

1060 BRICKELL AVE APT 1803
MIAMI FL
33131-3919
US

V. Phone/Fax

Practice location:
  • Phone: 954-384-1117
  • Fax:
Mailing address:
  • Phone: 847-212-1073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY10782
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.010289
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: