Provider Demographics
NPI:1902207285
Name:LANE, MELISSA DETTORE
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:DETTORE
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 1:66 BIRCHWOOD KNLS
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-3646
Mailing Address - Country:US
Mailing Address - Phone:215-432-3432
Mailing Address - Fax:
Practice Address - Street 1:66 BIRCHWOOD KNLS
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NJ
Practice Address - Zip Code:08648-3646
Practice Address - Country:US
Practice Address - Phone:215-432-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00571900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical