MEDICARE: COURTENEY LANE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	3853	TN

General Provider Information

NPI Number	:	1780141184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTENEY LANE

Provider Business Mailing Address
First Line	:	3641 MEMORIAL BLVD
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-3422
Country	:	US
Telephone Number	:	423-747-1275
Fax Number	:

Provider Business Practice Location Address
First Line	:	3641 MEMORIAL BLVD
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-3422
Country	:	US
Telephone Number	:	423-246-2411
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2019
Last Update Date	:	02/22/2019

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Directions to “ COURTENEY LANE ” Practice Location

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