Healthcare Provider Details

I. General information

NPI: 1952808701
Provider Name (Legal Business Name): LISA LANG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14135 NORTH CEDARBURG ROAD
MEQUON WI
53097
US

IV. Provider business mailing address

2027 NORTH 71ST STREET
WAUWATOSA WI
53213
US

V. Phone/Fax

Practice location:
  • Phone: 414-702-2324
  • Fax:
Mailing address:
  • Phone: 414-702-2119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number51-036
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number51-036
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier51-036
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerPSYCHOTHERAPY LICENSE #
# 2
Identifier01-226
Identifier TypeOTHER
Identifier State
Identifier IssuerATCB BOARD CERTIFICATION #
# 3
Identifier1902985922
Identifier TypeOTHER
Identifier State
Identifier IssuerINDIVIDUAL NPI #
# 4
Identifier40961100
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name: MS. LISA LANG
Title or Position: LICENSED PSYCHOTHERAPIST
Credential: MS, ATRL-BC
Phone: 414-702-2119