Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health | 5202007638 | MI |
NPI | 1093310591 |
---|---|
Provider Name | Brandon Michael Lange |
First Address | Allegan, MI 49010 |
Second Address | Allegan, MI 49010-1541 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/12/2020 |
Last Update Date | 02/12/2020 |