Provider Demographics
NPI:1144848920
Name:LANE, CARINA ELIZABETH
Entity type:Individual
Prefix:
First Name:CARINA
Middle Name:ELIZABETH
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 1:102 WATERBURY CIR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-7921
Mailing Address - Country:US
Mailing Address - Phone:773-312-3877
Mailing Address - Fax:
Practice Address - Street 1:102 WATERBURY CIR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7921
Practice Address - Country:US
Practice Address - Phone:773-312-3877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist