Provider Demographics
NPI:1124247226
Name:LANGE, KELLY L (PHD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:LANGE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
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Mailing Address - Street 1:9606 TIERRA GRANDE ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-6501
Mailing Address - Country:US
Mailing Address - Phone:858-693-3113
Mailing Address - Fax:
Practice Address - Street 1:9606 TIERRA GRANDE ST
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-6501
Practice Address - Country:US
Practice Address - Phone:858-693-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21401103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist