Provider Demographics
NPI:1467966333
Name:HARRIS, LANE WINSLOR JR
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:WINSLOR
Last Name:HARRIS
Suffix:JR
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 1:703 GREENBROUGH DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-3339
Mailing Address - Country:US
Mailing Address - Phone:863-651-2208
Mailing Address - Fax:
Practice Address - Street 1:703 GREENBROUGH DR
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-3339
Practice Address - Country:US
Practice Address - Phone:863-651-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$OtherMENTAL HEALTH