Provider Demographics
NPI:1053466508
Name:MCLANE, MICHAEL S (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:MCLANE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12830 HILLCREST RD STE D233
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-1527
Mailing Address - Country:US
Mailing Address - Phone:972-620-1225
Mailing Address - Fax:972-620-4393
Practice Address - Street 1:12860 HILLCREST RD
Practice Address - Street 2:SUITE G206
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-1530
Practice Address - Country:US
Practice Address - Phone:972-620-1225
Practice Address - Fax:972-620-4393
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31896103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist