Healthcare Provider Details

I. General information

NPI: 1780732073
Provider Name (Legal Business Name): DOUGLAS W LANE PH. D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2607 BRIDGEPORT WAY W STE 2E
UNIVERSITY PLACE WA
98466-4725
US

IV. Provider business mailing address

PO BOX 7182
TACOMA WA
98417-0182
US

V. Phone/Fax

Practice location:
  • Phone: 253-364-7814
  • Fax:
Mailing address:
  • Phone: 253-364-7814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY00003471
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: