Healthcare Provider Details

I. General information

NPI: 1508695339
Provider Name (Legal Business Name): TIANE LANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 S LIBERTY DR STE 4
BLOOMINGTON IN
47403-5178
US

IV. Provider business mailing address

1180 S LIBERTY DR STE 4
BLOOMINGTON IN
47403-5178
US

V. Phone/Fax

Practice location:
  • Phone: 812-200-2777
  • Fax:
Mailing address:
  • Phone: 812-200-2777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-379131
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: