Provider Demographics
NPI:1740845262
Name:LANHAM, MARY E (BSECE,RA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:LANHAM
Suffix:
Gender:F
Credentials:BSECE,RA
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSECE, RA
Mailing Address - Street 1:8445 MUNSON RD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-2410
Mailing Address - Country:US
Mailing Address - Phone:440-255-1700
Mailing Address - Fax:440-255-2441
Practice Address - Street 1:1083 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-1829
Practice Address - Country:US
Practice Address - Phone:440-358-7370
Practice Address - Fax:440-358-7373
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRA161723251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH284093Medicaid