Provider Demographics
NPI:1316413008
Name:LANE, ADAM J (LAADC)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:J
Last Name:LANE
Suffix:
Gender:M
Credentials:LAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 EMBER AVE FL USA
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-2429
Mailing Address - Country:US
Mailing Address - Phone:480-862-6033
Mailing Address - Fax:
Practice Address - Street 1:8633 KNOTT AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3852
Practice Address - Country:US
Practice Address - Phone:714-527-6561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13290101YA0400X
101YM0800X
CALR05270519101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty