Provider Demographics
NPI:1750344776
Name:LANE, THERESA LOUISE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LOUISE
Last Name:LANE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 SPRINGER RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13904-3409
Mailing Address - Country:US
Mailing Address - Phone:607-775-2691
Mailing Address - Fax:
Practice Address - Street 1:10-42 MITCHELL AVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1617
Practice Address - Country:US
Practice Address - Phone:607-762-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008321-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist