Provider Demographics
NPI:1861968901
Name:LANE, CORY (LMHCA, CDPT)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:LMHCA, CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W RIVMONT DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-9737
Mailing Address - Country:US
Mailing Address - Phone:301-367-7550
Mailing Address - Fax:
Practice Address - Street 1:999 164TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008-3518
Practice Address - Country:US
Practice Address - Phone:425-274-8394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60831028101YM0800X
WACO60788417101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)