Basic Information
| Provider Information | |||||||||
| NPI: | 1396902961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCLANE | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | RUTH-COOMBS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.M.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3475 BELLE CHASE WAY | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178823732 | ||||||||
| FaxNumber: | 5178823633 | ||||||||
| Practice Location | |||||||||
| Address1: | 3475 BELLE CHASE WAY | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178823732 | ||||||||
| FaxNumber: | 5178823633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 10/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801083840 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 80-0-89-7196-0 | 01 | MI | BLUE CROSS / BLUE SHIED | OTHER | 371499462 | 01 | MI | MAGELLAN | OTHER |