Provider Demographics
NPI:1073114898
Name:WILLMOTT, LANE WESTON
Entity Type:Individual
Prefix:MR
First Name:LANE
Middle Name:WESTON
Last Name:WILLMOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:BLAIR
Mailing Address - State:NE
Mailing Address - Zip Code:68008-1211
Mailing Address - Country:US
Mailing Address - Phone:402-619-3209
Mailing Address - Fax:
Practice Address - Street 1:8922 CUMING ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2732
Practice Address - Country:US
Practice Address - Phone:402-926-4373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NERBT-20140944106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician