Provider Demographics
NPI:1003198623
Name:LANE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
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 1:298 BROMPTON RD S
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6701 110TH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2378
Practice Address - Country:US
Practice Address - Phone:718-268-3137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-10
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist