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General NPI Number Information
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NPI Number | 1538958517
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Entity Type | Individual
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Provider Name | LANGE K PAYNE LPC, LMFTA
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Gender | Male
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Dates
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Enumeration Date | 05/05/2025
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Last Update Date | 05/05/2025
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Provider Practice Location Address
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Address Line | 808 S ELDORADO RD STE 300
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City | BLOOMINGTON
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State | IL
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Zip | 61704-6009
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Country | US
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Telephone | 660-624-0646
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Fax |
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Provider Business Mailing Address
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Address Line | 2820 RICHARD RD
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City | BLOOMINGTON
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State | IL
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Zip | 61704-4640
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Country | US
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Telephone | 660-624-0646
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 178.021396
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License Number State | IL
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