Provider Demographics
NPI:1518663186
Name:LANE, DAJA ANDREA
Entity Type:Individual
Prefix:
First Name:DAJA
Middle Name:ANDREA
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30434-6503
Mailing Address - Country:US
Mailing Address - Phone:478-206-6180
Mailing Address - Fax:
Practice Address - Street 1:408 1ST ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:GA
Practice Address - Zip Code:30434-6503
Practice Address - Country:US
Practice Address - Phone:478-206-6180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician