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General NPI Number Information
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NPI Number | 1083122147
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Entity Type | Individual
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Provider Name | NICHOLAS MARK LANGE LPC/LMFT
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Gender | Male
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Dates
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Enumeration Date | 01/11/2018
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Last Update Date | 08/24/2023
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Provider Practice Location Address
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Address Line | 6255 28TH ST. SE SUITE 3, OFFICES C&D
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City | GRAND RAPIDS
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State | MI
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Zip | 49546
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Country | US
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Telephone | 231-286-2355
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Fax |
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Provider Business Mailing Address
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Address Line | 599 OAK MEADOW DR
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City | MIDDLEVILLE
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State | MI
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Zip | 49333-8478
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Country | US
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Telephone | 231-286-2355
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 4101007011
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6401018602
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License Number State | MI
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