Provider Demographics
NPI:1598126740
Name:LANE TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:LANE TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ENGWALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:410-837-4292
Mailing Address - Street 1:2117 MARYLAND AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5614
Mailing Address - Country:US
Mailing Address - Phone:410-244-7350
Mailing Address - Fax:410-244-7351
Practice Address - Street 1:2117 MARYLAND AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5614
Practice Address - Country:US
Practice Address - Phone:410-244-7350
Practice Address - Fax:410-244-7351
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAN ALIVE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMH-1858225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Single Specialty