Provider Demographics
NPI:1568033025
Name:BEHAVIORAL LANE
Entity type:Organization
Organization Name:BEHAVIORAL LANE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:904-250-0852
Mailing Address - Street 1:7603 ALTAMA RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-9309
Mailing Address - Country:US
Mailing Address - Phone:904-250-0852
Mailing Address - Fax:
Practice Address - Street 1:7603 ALTAMA RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-9309
Practice Address - Country:US
Practice Address - Phone:904-250-0852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty