Provider Demographics
NPI:1356481014
Name:LANE, DAVID BALLARD JR (LMSW, LLP, LPC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BALLARD
Last Name:LANE
Suffix:JR
Gender:M
Credentials:LMSW, LLP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9422
Mailing Address - Country:US
Mailing Address - Phone:989-362-8636
Mailing Address - Fax:
Practice Address - Street 1:1199 HARRIS AVE
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9681
Practice Address - Country:US
Practice Address - Phone:989-362-8636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401000213101YP2500X
MI6301003884103T00000X
MI68010162311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401000213OtherLPC
MI6301003884OtherLLP
MI6801016231OtherLMSW