Healthcare Provider Details

I. General information

NPI: 1588768154
Provider Name (Legal Business Name): CAROL J LANE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 HAMMOND ST
BANGOR ME
04401-4328
US

IV. Provider business mailing address

797 WILSON ST
BREWER ME
04412-1000
US

V. Phone/Fax

Practice location:
  • Phone: 207-992-4042
  • Fax: 207-992-4043
Mailing address:
  • Phone: 207-924-0077
  • Fax: 207-924-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT1423
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: