Provider Demographics
NPI:1588768154
Name:LANE, CAROL J (PT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:J
Last Name:LANE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:797 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1000
Mailing Address - Country:US
Mailing Address - Phone:207-924-0077
Mailing Address - Fax:207-924-0078
Practice Address - Street 1:890 HAMMOND ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4328
Practice Address - Country:US
Practice Address - Phone:207-992-4042
Practice Address - Fax:207-992-4043
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1423225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MM759201OtherMEDICARE PTAN