Provider Demographics
NPI:1124113709
Name:DELANGE, TALMAGE W (MED, LCPC)
Entity type:Individual
Prefix:
First Name:TALMAGE
Middle Name:W
Last Name:DELANGE
Suffix:
Gender:M
Credentials:MED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 DEWEY STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647
Mailing Address - Country:US
Mailing Address - Phone:208-724-8120
Mailing Address - Fax:208-587-2992
Practice Address - Street 1:235 NORTH 3RD EAST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647
Practice Address - Country:US
Practice Address - Phone:208-724-8120
Practice Address - Fax:208-587-2992
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC 382101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ5944OtherBLUE CROSS BLUE SHIELD