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General NPI Number Information
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NPI Number | 1972927861
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Entity Type | Organization
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Legal Business Name | TYRONE D. LANE ENTERPRISES, INCORPORATED
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Dates
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Enumeration Date | 02/12/2014
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Last Update Date | 02/12/2014
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Provider Practice Location Address
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Address Line | 5304 PANOLA INDUSTRIAL BOULEVARD SUITE L
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City | DECATUR
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State | GA
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Zip | 30035
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Country | US
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Telephone | 678-677-4041
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Fax |
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Provider Business Mailing Address
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Address Line | 5304 PANOLA INDUSTRIAL BOULEVARD SUITE L
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City | DECATUR
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State | GA
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Zip | 30035
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Country | US
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Telephone | 678-677-4041
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MR. TYRONE D. LANE
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Credential | MPSY
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Telephone | 678-677-4041
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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