Basic Information
| Provider Information | |||||||||
| NPI: | 1205358009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | ANNIE | ||||||||
| MiddleName: | FORBES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 396 | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450660396 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 902 GALLIA ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405292125 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2017 | ||||||||
| LastUpdateDate: | 05/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | BP00942485 | WV | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | S.1903661 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.