Provider Demographics
NPI:1366836199
Name:LANE, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 COMMERCIAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-3640
Mailing Address - Country:US
Mailing Address - Phone:774-260-1242
Mailing Address - Fax:
Practice Address - Street 1:2 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-3640
Practice Address - Country:US
Practice Address - Phone:774-260-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3848224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant