Provider Demographics
NPI:1558414755
Name:LANE, WALTER (BA MHA)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:BA MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S FRONT AVE
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1614
Mailing Address - Country:US
Mailing Address - Phone:606-886-8572
Mailing Address - Fax:606-886-4433
Practice Address - Street 1:118 RIVER DR
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1597
Practice Address - Country:US
Practice Address - Phone:606-432-3143
Practice Address - Fax:606-437-5412
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health