Provider Demographics
NPI:1700127156
Name:LANE, MARK (LICSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 TRADECENTER STE 5900
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-7471
Mailing Address - Country:US
Mailing Address - Phone:617-209-9477
Mailing Address - Fax:
Practice Address - Street 1:400 TRADECENTER STE 5900
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-7471
Practice Address - Country:US
Practice Address - Phone:617-209-9477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MA1233431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator