Healthcare Provider Details

I. General information

NPI: 1346959921
Provider Name (Legal Business Name): ELISA KAITLYN LANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 ELLICOTT ST
BATAVIA NY
14020-3650
US

IV. Provider business mailing address

55 DODGE RD
GETZVILLE NY
14068-1205
US

V. Phone/Fax

Practice location:
  • Phone: 585-815-0247
  • Fax:
Mailing address:
  • Phone: 716-831-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: