Provider Demographics
NPI:1427532415
Name:LANGE, MARTHA TANIA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:TANIA
Last Name:LANGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:M
Other - Middle Name:TANIA
Other - Last Name:LANGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3661 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8218
Mailing Address - Country:US
Mailing Address - Phone:239-245-8761
Mailing Address - Fax:239-689-8694
Practice Address - Street 1:3661 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8218
Practice Address - Country:US
Practice Address - Phone:392-458-7612
Practice Address - Fax:239-689-8694
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-55096106S00000X
1-21-50783103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician