Provider Demographics
NPI:1396984779
Name:LANE, CLYTHA LAWANZA
Entity type:Individual
Prefix:MRS
First Name:CLYTHA
Middle Name:LAWANZA
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 BENNINGTON HILLS CT
Mailing Address - Street 2:
Mailing Address - City:WEST HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14586-9768
Mailing Address - Country:US
Mailing Address - Phone:585-334-6166
Mailing Address - Fax:585-334-6166
Practice Address - Street 1:147 BENNINGTON HILLS CT
Practice Address - Street 2:
Practice Address - City:WEST HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14586-9768
Practice Address - Country:US
Practice Address - Phone:585-334-6166
Practice Address - Fax:585-334-6166
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008314-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist