=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194795179
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARLENE LANE M.S., CCC-A/ FAAA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2006
-----------------------------------------------------
Last Update Date | 10/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 WORCESTER ST
-----------------------------------------------------
City | WELLESLEY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02481-5420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-431-5275
-----------------------------------------------------
Fax | 871-431-5583
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 230 WORCESTER ST
-----------------------------------------------------
City | WELLESLEY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02481-5420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-431-5275
-----------------------------------------------------
Fax | 871-431-5583
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 679
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------