Provider Demographics
NPI:1992778435
Name:LANE, MARK EDWARD (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:LANE
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 WESTCHESTER DR S
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-4212
Mailing Address - Country:US
Mailing Address - Phone:518-421-2628
Mailing Address - Fax:518-439-1237
Practice Address - Street 1:5 PINE WEST PLAZA, SUITE 508
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205
Practice Address - Country:US
Practice Address - Phone:518-421-2628
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045735-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical