Provider Demographics
NPI:1619551595
Name:LANE, CAMRYN
Entity Type:Individual
Prefix:
First Name:CAMRYN
Middle Name:
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 1:1765 FOX RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8679
Mailing Address - Country:US
Mailing Address - Phone:269-449-2267
Mailing Address - Fax:
Practice Address - Street 1:5281 CLYDE PARK AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9506
Practice Address - Country:US
Practice Address - Phone:616-719-4263
Practice Address - Fax:616-719-4267
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician