Provider Demographics
NPI:1932819083
Name:LANE, SCOTT GALE
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:GALE
Last Name:LANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1543
Mailing Address - Country:US
Mailing Address - Phone:719-545-1181
Mailing Address - Fax:
Practice Address - Street 1:3500 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1543
Practice Address - Country:US
Practice Address - Phone:719-545-1181
Practice Address - Fax:719-545-1191
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0004528101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
COACC.0004528OtherCERTIFIED ADDICTIONS SPECIALIST