=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427543131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY LANGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2018
-----------------------------------------------------
Last Update Date | 06/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 LAMINGTON RD
-----------------------------------------------------
City | BRANCHBURG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08876-3374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-655-6926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 376 VAN HOLTEN RD
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-1946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-655-6926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 18KT00203500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------