Healthcare Provider Details

I. General information

NPI: 1629469622
Provider Name (Legal Business Name): SEMETRIA LANE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19104 ELKHART ST
HARPER WOODS MI
48225-2108
US

IV. Provider business mailing address

19104 ELKHART ST
HARPER WOODS MI
48225-2108
US

V. Phone/Fax

Practice location:
  • Phone: 248-914-1710
  • Fax:
Mailing address:
  • Phone: 248-914-1710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name: SEMETRIA LANE
Title or Position: ABA TECH
Credential:
Phone: 248-914-1710