Provider Demographics
NPI:1548222342
Name:LANE, MARLIS J (OTR CDRS)
Entity Type:Individual
Prefix:MRS
First Name:MARLIS
Middle Name:J
Last Name:LANE
Suffix:
Gender:F
Credentials:OTR CDRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 W VINE DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-1621
Mailing Address - Country:US
Mailing Address - Phone:970-482-8923
Mailing Address - Fax:
Practice Address - Street 1:1045 ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3926
Practice Address - Country:US
Practice Address - Phone:970-493-6667
Practice Address - Fax:970-493-8016
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAA635391225X00000X, 225XR0403X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility