Provider Demographics
NPI:1568656361
Name:LANE, MARA H (CCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:MARA
Middle Name:H
Last Name:LANE
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 GREENBRIAR EAST DR
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5064
Mailing Address - Country:US
Mailing Address - Phone:847-945-8977
Mailing Address - Fax:
Practice Address - Street 1:140 GREENBRIAR EAST DR
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5064
Practice Address - Country:US
Practice Address - Phone:847-945-8977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist