Provider Demographics
NPI:1295334639
Name:LANE, TIMOTHY STANLEY (MDIV AND DMIN)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:STANLEY
Last Name:LANE
Suffix:
Gender:M
Credentials:MDIV AND DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SIDNEY LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-7646
Mailing Address - Country:US
Mailing Address - Phone:770-371-6821
Mailing Address - Fax:
Practice Address - Street 1:50 EASTBROOK BND STE B
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1530
Practice Address - Country:US
Practice Address - Phone:678-519-5259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral