Provider Demographics
NPI:1942756770
Name:CHAZDON, LANE (LCAT, MME, MT-BC)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:
Last Name:CHAZDON
Suffix:
Gender:M
Credentials:LCAT, MME, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:NY
Mailing Address - Zip Code:10548
Mailing Address - Country:US
Mailing Address - Phone:914-737-4400
Mailing Address - Fax:
Practice Address - Street 1:2094 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:NY
Practice Address - Zip Code:10548-1454
Practice Address - Country:US
Practice Address - Phone:914-737-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0000462-1225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000462-1OtherNY STATE LICENSE
NY8445678OtherNY STATE LICENSE CERTIFICATION