Provider Demographics
NPI:1760574370
Name:LANE, ARDYS DEANE
Entity Type:Individual
Prefix:
First Name:ARDYS
Middle Name:DEANE
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ARDYS
Other - Middle Name:DEANE
Other - Last Name:WHIPPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:CONCRETE
Mailing Address - State:WA
Mailing Address - Zip Code:98237-0515
Mailing Address - Country:US
Mailing Address - Phone:360-853-7860
Mailing Address - Fax:
Practice Address - Street 1:1100 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4209
Practice Address - Country:US
Practice Address - Phone:360-419-3500
Practice Address - Fax:360-419-3505
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00027484101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health