Provider Demographics
NPI:1174576706
Name:LACLAIR, LANE THOMAS (DPT, CSCS, NSCA-CPT)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:THOMAS
Last Name:LACLAIR
Suffix:
Gender:M
Credentials:DPT, CSCS, NSCA-CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-1303
Mailing Address - Country:US
Mailing Address - Phone:262-878-9602
Mailing Address - Fax:262-878-9609
Practice Address - Street 1:1201 MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-1303
Practice Address - Country:US
Practice Address - Phone:262-878-9602
Practice Address - Fax:262-878-9609
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9917024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40384500Medicaid
ILK17392Medicare ID - Type Unspecified
WI40384500Medicaid