Provider Demographics
NPI:1710009840
Name:LANE, JAMES W (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:LANE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:ATTN CREDENTIALING DEPT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:314-810-1399
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:SUITE 215
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8501
Practice Address - Country:US
Practice Address - Phone:618-288-5711
Practice Address - Fax:618-288-4088
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2008-02-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK36777Medicare PIN