Provider Demographics
NPI:1962662668
Name:LANE, WILLIAM JOHN (OTR/L)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOHN
Last Name:LANE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 BIRCH WOOD
Mailing Address - Street 2:
Mailing Address - City:EAGLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97524-9717
Mailing Address - Country:US
Mailing Address - Phone:541-890-7716
Mailing Address - Fax:
Practice Address - Street 1:25117 SW PARKWAY AVE STE D
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9697
Practice Address - Country:US
Practice Address - Phone:503-570-3665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1034519225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist