Provider Demographics
NPI:1356570600
Name:LANE, MATTHEW P (EDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:LANE
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 SW 27TH AVENUE
Mailing Address - Street 2:UNIT 1
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471
Mailing Address - Country:US
Mailing Address - Phone:352-237-3440
Mailing Address - Fax:352-237-4381
Practice Address - Street 1:3021 SW 27TH AVENUE
Practice Address - Street 2:UNIT 1
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471
Practice Address - Country:US
Practice Address - Phone:352-237-3440
Practice Address - Fax:352-237-4381
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS599103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist