Provider Demographics
NPI:1730646894
Name:LANGE, SAMUEL ZACHARY (LMFT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ZACHARY
Last Name:LANGE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 SONOMA AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4812
Mailing Address - Country:US
Mailing Address - Phone:707-293-6486
Mailing Address - Fax:
Practice Address - Street 1:1144 SONOMA AVE STE 104
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4812
Practice Address - Country:US
Practice Address - Phone:707-293-6486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86694106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist