Provider Demographics
NPI:1174170708
Name:CYNTHIA LOUISE LANGE, LLC
Entity type:Organization
Organization Name:CYNTHIA LOUISE LANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-221-1161
Mailing Address - Street 1:330 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6403
Mailing Address - Country:US
Mailing Address - Phone:406-848-4827
Mailing Address - Fax:
Practice Address - Street 1:330 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6403
Practice Address - Country:US
Practice Address - Phone:406-848-4827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty