Provider Demographics
NPI:1003941915
Name:LANE, WANDALYN (MA)
Entity Type:Individual
Prefix:MS
First Name:WANDALYN
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 HUGHES WAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810-1876
Mailing Address - Country:US
Mailing Address - Phone:310-221-6336
Mailing Address - Fax:
Practice Address - Street 1:1585 S D ST
Practice Address - Street 2:101
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3257
Practice Address - Country:US
Practice Address - Phone:909-388-2222
Practice Address - Fax:909-388-2220
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health