Provider Demographics
NPI:1144310186
Name:LANE, DANIEL RAY (LMSW)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAY
Last Name:LANE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4803 OLYMPIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310
Mailing Address - Country:US
Mailing Address - Phone:940-613-0757
Mailing Address - Fax:
Practice Address - Street 1:149 HART STREET
Practice Address - Street 2:82 MEDICAL GROUP SGH
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3482
Practice Address - Country:US
Practice Address - Phone:940-676-3022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010765811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN