Healthcare Provider Details

I. General information

NPI: 1356481014
Provider Name (Legal Business Name): DAVID BALLARD LANE JR. LMSW, LLP, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 HARRIS AVE
TAWAS CITY MI
48763-9681
US

IV. Provider business mailing address

1635 DOUGLAS DR
TAWAS CITY MI
48763-9422
US

V. Phone/Fax

Practice location:
  • Phone: 989-362-8636
  • Fax:
Mailing address:
  • Phone: 989-362-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401000213
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301003884
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801016231
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: