Basic Information
| Provider Information | |||||||||
| NPI: | 1669839890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANGE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | CODY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35052 CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923992863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517750557 | ||||||||
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| Practice Location | |||||||||
| Address1: | 790 VIA LATA STE 300 | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923243978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094330445 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2016 | ||||||||
| LastUpdateDate: | 12/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.