Provider Demographics
NPI:1215743851
Name:LANE, CHARLES J
Entity type:Individual
Prefix:
First Name:CHARLES
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 1:37 SNOW ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3412
Mailing Address - Country:US
Mailing Address - Phone:857-210-4072
Mailing Address - Fax:
Practice Address - Street 1:1 MEETING HOUSE RD STE 11
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-2737
Practice Address - Country:US
Practice Address - Phone:978-485-4722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2286401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical