Provider Demographics
NPI:1942836325
Name:LANE, BRITTNEY A
Entity type:Individual
Prefix:
First Name:BRITTNEY
Middle Name:A
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 1:1700 MCHENRY VILLAGE WAY STE 11B
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4341
Mailing Address - Country:US
Mailing Address - Phone:209-550-5850
Mailing Address - Fax:
Practice Address - Street 1:1700 MCHENRY VILLAGE WAY STE 11B
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4341
Practice Address - Country:US
Practice Address - Phone:209-550-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CABHS-MH171M00000X
CA390200000X
CA17689101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program