Provider Demographics
NPI:1548907892
Name:LANGE, KELLY ANN KING (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN KING
Last Name:LANGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3128 PARKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-3537
Mailing Address - Country:US
Mailing Address - Phone:954-465-7494
Mailing Address - Fax:
Practice Address - Street 1:1503 SANTA ROSA RD RM 105
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5105
Practice Address - Country:US
Practice Address - Phone:954-465-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040139591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1043348741Other02-ORGANIZATION