Provider Demographics
NPI:1659032126
Name:LANE, MARNIE-JEAN
Entity Type:Individual
Prefix:
First Name:MARNIE-JEAN
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 1:58 MISSIONARY RD
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2134
Mailing Address - Country:US
Mailing Address - Phone:860-754-4862
Mailing Address - Fax:860-632-3219
Practice Address - Street 1:58 MISSIONARY RD
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2134
Practice Address - Country:US
Practice Address - Phone:860-754-4862
Practice Address - Fax:860-632-3219
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1010103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst