Healthcare Provider Details

I. General information

NPI: 1831900042
Provider Name (Legal Business Name): ADAM LANE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 POMFRET ST
PUTNAM CT
06260-1869
US

IV. Provider business mailing address

189 GOSHEN RD
MOOSUP CT
06354-2012
US

V. Phone/Fax

Practice location:
  • Phone: 860-963-6385
  • Fax: 860-963-6034
Mailing address:
  • Phone: 860-450-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number10717
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: