Provider Demographics
NPI:1245099696
Name:LANE, DOMINIC THOMAS
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:THOMAS
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 1:91 FOSTER LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-4411
Mailing Address - Country:US
Mailing Address - Phone:386-334-0094
Mailing Address - Fax:
Practice Address - Street 1:1408 NW 6TH ST FL 32601
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4020
Practice Address - Country:US
Practice Address - Phone:352-373-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT-24-324980106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician