Healthcare Provider Details

I. General information

NPI: 1972927861
Provider Name (Legal Business Name): TYRONE D. LANE ENTERPRISES, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

5304 PANOLA INDUSTRIAL BOULEVARD SUITE L
DECATUR GA
30035
US

IV. Provider business mailing address

5304 PANOLA INDUSTRIAL BOULEVARD SUITE L
DECATUR GA
30035
US

V. Phone/Fax

Practice location:
  • Phone: 678-677-4041
  • Fax:
Mailing address:
  • Phone: 678-677-4041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. TYRONE D. LANE
Title or Position: PRESIDENT/CEO
Credential: MPSY
Phone: 678-677-4041