Provider Demographics
NPI:1144372756
Name:LANE, COLETHA P
Entity type:Individual
Prefix:MRS
First Name:COLETHA
Middle Name:P
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6810
Mailing Address - Country:US
Mailing Address - Phone:904-360-7022
Mailing Address - Fax:904-798-4544
Practice Address - Street 1:910 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6810
Practice Address - Country:US
Practice Address - Phone:904-360-7022
Practice Address - Fax:904-798-4544
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811824800Medicaid
FL767404000Medicaid