Provider Demographics
NPI:1194795179
Name:LANE, MARLENE (MS, CCC-A/ FAAA)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:MS, CCC-A/ FAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 WORCESTER ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-5420
Mailing Address - Country:US
Mailing Address - Phone:781-431-5275
Mailing Address - Fax:871-431-5583
Practice Address - Street 1:230 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-5420
Practice Address - Country:US
Practice Address - Phone:781-431-5275
Practice Address - Fax:871-431-5583
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA679231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0022337OtherNEIGHBORHOOD HEALTH PLAN
MAAD0162OtherBLUE CROSS
MAPJ221OtherHARVARD PILGRIM
MA5100992Medicaid
MAB501027OtherCIGNA
MAP00202525OtherMEDICARE RAILROAD
MA021464Medicare ID - Type Unspecified