Provider Demographics
NPI:1104344795
Name:LANE, MICHAEL CARRINGTON (COTA/L)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CARRINGTON
Last Name:LANE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 WESTCHESTER SQ APT 2F
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:EASTCHESTER
Practice Address - State:NY
Practice Address - Zip Code:10709-5506
Practice Address - Country:US
Practice Address - Phone:914-793-6130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-02
Last Update Date:2017-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009251-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant