Provider Demographics
NPI:1376255786
Name:LANE, MARYSSA (RBT)
Entity Type:Individual
Prefix:
First Name:MARYSSA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:MARYSSA
Other - Middle Name:
Other - Last Name:ASHTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 258831
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73125-8831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8354 E NORTHFIELD BLVD UNIT 3700
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-3135
Practice Address - Country:US
Practice Address - Phone:720-961-3764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician