Basic Information
| Provider Information | |||||||||
| NPI: | 1316413008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LAADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6355 EMBER AVE FL USA | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329272429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808626033 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8633 KNOTT AVE | ||||||||
| Address2: | |||||||||
| City: | BUENA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906203852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145276561 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2018 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 13290 | AZ | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | LR05270519 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.