Healthcare Provider Details

I. General information

NPI: 1548681786
Provider Name (Legal Business Name): AMY LANE APRN, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2013
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 SALEM TPKE
BOZRAH CT
06334-1519
US

IV. Provider business mailing address

410 SALEM TPKE
BOZRAH CT
06334-1519
US

V. Phone/Fax

Practice location:
  • Phone: 860-823-0245
  • Fax: 860-213-8350
Mailing address:
  • Phone: 860-823-0245
  • Fax: 860-213-8350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number002158
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number002158
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number002158
License Number StateCT

VIII. Authorized Official

Name: AMY MICHELLE LANE
Title or Position: APRN
Credential: APRN
Phone: 860-823-0245