Healthcare Provider Details

I. General information

NPI: 1275245573
Provider Name (Legal Business Name): JEREMIAH LANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 S MAIN ST STE 101
CLARKSTON MI
48346-2377
US

IV. Provider business mailing address

496 WIMPOLE DR
ROCHESTER HILLS MI
48309-2152
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-2970
  • Fax:
Mailing address:
  • Phone: 248-854-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: