Provider Demographics
NPI:1326343930
Name:LANE, THERESA MARIE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:LANE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 E NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-6016
Mailing Address - Country:US
Mailing Address - Phone:516-503-4017
Mailing Address - Fax:
Practice Address - Street 1:1812 GARDENIA AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-1503
Practice Address - Country:US
Practice Address - Phone:516-503-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020598235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12118626OtherASHA