Provider Demographics
NPI:1215377494
Name:LANE, ELLIOTT EMERSON
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:EMERSON
Last Name:LANE
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 1:660 WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-1969
Mailing Address - Country:US
Mailing Address - Phone:203-776-8390
Mailing Address - Fax:203-776-4176
Practice Address - Street 1:660 WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-1969
Practice Address - Country:US
Practice Address - Phone:203-776-8390
Practice Address - Fax:203-776-4176
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical