Provider Demographics
NPI:1487159364
Name:LANE, MADILYN ANN
Entity type:Individual
Prefix:
First Name:MADILYN
Middle Name:ANN
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 SQUALL WAY APT 212
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8495
Mailing Address - Country:US
Mailing Address - Phone:217-972-3571
Mailing Address - Fax:
Practice Address - Street 1:3113 SQUALL WAY APT 212
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8495
Practice Address - Country:US
Practice Address - Phone:217-972-3571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-24
Last Update Date:2018-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty