Provider Demographics
NPI:1790200541
Name:LAINE, ROBIN LYNN
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:LYNN
Last Name:LAINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1012
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MT
Mailing Address - Zip Code:59474-1012
Mailing Address - Country:US
Mailing Address - Phone:208-573-1066
Mailing Address - Fax:
Practice Address - Street 1:529 PARK AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MT
Practice Address - Zip Code:59474-2131
Practice Address - Country:US
Practice Address - Phone:208-573-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-12
Last Update Date:2017-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-4927101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)