Provider Demographics
NPI:1164263497
Name:LANE, MICHAELA (SLP)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 W 5TH ST OFC 2876B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90071-2005
Mailing Address - Country:US
Mailing Address - Phone:512-399-0064
Mailing Address - Fax:
Practice Address - Street 1:5126 MINTWORTH COMMONS DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-8521
Practice Address - Country:US
Practice Address - Phone:423-833-2032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30002514235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist