Provider Demographics
NPI:1295927176
Name:LANE, DAVID (COTA/L,MHA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:COTA/L,MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BRIARMIST CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-6318
Mailing Address - Country:US
Mailing Address - Phone:636-379-4441
Mailing Address - Fax:
Practice Address - Street 1:19 BRIARMIST CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-6318
Practice Address - Country:US
Practice Address - Phone:636-379-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000157289224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant