Provider Demographics
NPI:1376742890
Name:LANE, CARLA L (LMP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:L
Last Name:LANE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 PIRATES WAY
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-9405
Mailing Address - Country:US
Mailing Address - Phone:360-581-6117
Mailing Address - Fax:
Practice Address - Street 1:501 8TH ST
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550-3520
Practice Address - Country:US
Practice Address - Phone:360-581-6117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018325225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist