Provider Demographics
NPI:1154757821
Name:LANGE, NICHOLE (LCSW, LAC)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7731 SW 68TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-2709
Mailing Address - Country:US
Mailing Address - Phone:307-267-3882
Mailing Address - Fax:
Practice Address - Street 1:7731 SW 68TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-2709
Practice Address - Country:US
Practice Address - Phone:307-267-3882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLSW.0009920222104100000X
COACD.0000866101YA0400X
COCSW.099240741041C0700X
FLSW172211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)