Provider Demographics
NPI:1033551106
Name:LANE, CONSTANCE RUSSELL (MAOTR)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:RUSSELL
Last Name:LANE
Suffix:
Gender:F
Credentials:MAOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8792 E MINERAL CIR
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-2748
Mailing Address - Country:US
Mailing Address - Phone:303-809-4058
Mailing Address - Fax:
Practice Address - Street 1:8792 E MINERAL CIR
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-2748
Practice Address - Country:US
Practice Address - Phone:303-809-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2362225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2362OtherCOLORADO STATE LICENSE
AA407379OtherNBCOT