Provider Demographics
NPI:1164184990
Name:LANE, MIKE NEAL (MFT)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:NEAL
Last Name:LANE
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 OCEAN PARK BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3231
Mailing Address - Country:US
Mailing Address - Phone:310-429-9727
Mailing Address - Fax:
Practice Address - Street 1:948 20TH ST UNIT C
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-3385
Practice Address - Country:US
Practice Address - Phone:310-429-9727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC33336106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist