MEDICARE: ANTWON SHANK-LANE JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1952142614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTWON SHANK-LANE JR.

Provider Business Mailing Address
First Line	:	1715 SPRINGFIELD ST STE 8B
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45403-1431
Country	:	US
Telephone Number	:	937-274-8854
Fax Number	:

Provider Business Practice Location Address
First Line	:	1715 SPRINGFIELD ST STE 8B
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45403-1431
Country	:	US
Telephone Number	:	937-274-8854
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2024
Last Update Date	:	06/05/2024

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