Provider Demographics
NPI:1215450234
Name:LANE, MARY (LISW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 GEORGE W BRUMLEY WAY SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30317-1743
Mailing Address - Country:US
Mailing Address - Phone:404-373-6614
Mailing Address - Fax:404-373-2926
Practice Address - Street 1:1401 HOSEA WILLIAMS DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30317-1703
Practice Address - Country:US
Practice Address - Phone:404-373-6614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0070411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003244836AMedicaid