Provider Demographics
NPI:1740602879
Name:LANE-O'BRIEN, STACIE (BCBA)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:LANE-O'BRIEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8307 SPANISH RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-9036
Mailing Address - Country:US
Mailing Address - Phone:319-330-0598
Mailing Address - Fax:
Practice Address - Street 1:8307 SPANISH RD
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-9036
Practice Address - Country:US
Practice Address - Phone:319-330-0598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-13-14345103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst