Provider Demographics
NPI:1992246581
Name:LANGE, TAMARA (MA)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:LANGE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CENTENNIAL DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-7939
Mailing Address - Country:US
Mailing Address - Phone:978-522-5055
Mailing Address - Fax:
Practice Address - Street 1:9 CENTENNIAL DR
Practice Address - Street 2:SUITE 202
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-7939
Practice Address - Country:US
Practice Address - Phone:978-522-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3031612104100000X
MA1178106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA04-2867023Medicaid