Healthcare Provider Details

I. General information

NPI: 1710553573
Provider Name (Legal Business Name): BRENT ALAN LANG PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 12/28/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 FISH POND RD
WACO TX
76710-1031
US

IV. Provider business mailing address

PO BOX 844658
DALLAS TX
75284-4658
US

V. Phone/Fax

Practice location:
  • Phone: 254-761-4444
  • Fax: 254-761-4441
Mailing address:
  • Phone: 254-724-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number38710
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number38710
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number38710
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number38710
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number38710
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: