Healthcare Provider Details

I. General information

NPI: 1639907561
Provider Name (Legal Business Name): JAMES HUNTER LANGE LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 HASLER VALLEY RD
GALLUP NM
87301
US

IV. Provider business mailing address

PO BOX 1723
GALLUP NM
87305-1723
US

V. Phone/Fax

Practice location:
  • Phone: 505-481-0219
  • Fax:
Mailing address:
  • Phone: 505-481-0219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2023-0168
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: