Basic Information
| Provider Information | |||||||||
| NPI: | 1275044760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEST | ||||||||
| FirstName: | LANE | ||||||||
| MiddleName: | PHOENIX | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 E HIGH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430502745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403236366 | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197749969 | ||||||||
| FaxNumber: | 4197565642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2017 | ||||||||
| LastUpdateDate: | 10/24/2017 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.