Provider Demographics
NPI:1679905699
Name:LANE, TISHA JANE
Entity type:Individual
Prefix:MRS
First Name:TISHA
Middle Name:JANE
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 1:15879 WILLOUGHBY LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-2416
Mailing Address - Country:US
Mailing Address - Phone:239-349-0216
Mailing Address - Fax:941-275-6307
Practice Address - Street 1:15879 WILLOUGHBY LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-2416
Practice Address - Country:US
Practice Address - Phone:239-349-0216
Practice Address - Fax:941-275-6307
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105953500Medicaid