Provider Demographics
NPI:1871001594
Name:LAINE, WANDA LYNN (CAP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LYNN
Last Name:LAINE
Suffix:
Gender:F
Credentials:CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 RADCLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NH
Mailing Address - Zip Code:03051-4743
Mailing Address - Country:US
Mailing Address - Phone:603-305-4048
Mailing Address - Fax:
Practice Address - Street 1:650 SUFFOLK ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-3642
Practice Address - Country:US
Practice Address - Phone:978-452-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAP100114101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty