Provider Demographics
NPI:1942301056
Name:LANE, SANDRA JO (LCSW, BCD, CGP)
Entity Type:Individual
Prefix:
First Name:SANDRA JO
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LCSW, BCD, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 HALF HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-6233
Mailing Address - Country:US
Mailing Address - Phone:631-586-7429
Mailing Address - Fax:631-254-1228
Practice Address - Street 1:627 HALF HOLLOW RD
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6233
Practice Address - Country:US
Practice Address - Phone:631-586-7429
Practice Address - Fax:631-254-1228
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYSR284541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02734485Medicaid
NYN34971Medicare ID - Type Unspecified