Provider Demographics
NPI:1801612148
Name:LANE, LANDON J
Entity type:Individual
Prefix:
First Name:LANDON
Middle Name:J
Last Name:LANE
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 1:15 S WOODBERRY RD
Mailing Address - Street 2:
Mailing Address - City:BURRTON
Mailing Address - State:KS
Mailing Address - Zip Code:67020-8933
Mailing Address - Country:US
Mailing Address - Phone:620-778-3910
Mailing Address - Fax:
Practice Address - Street 1:15 S WOODBERRY RD
Practice Address - Street 2:
Practice Address - City:BURRTON
Practice Address - State:KS
Practice Address - Zip Code:67020-8933
Practice Address - Country:US
Practice Address - Phone:620-778-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst