Basic Information
| Provider Information | |||||||||
| NPI: | 1528676582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LMSW-ACP, QMHP, CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 54 | ||||||||
| Address2: | |||||||||
| City: | MOYOCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279580054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577168364 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3322 WESTERN BRANCH BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233215142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576733644 | ||||||||
| FaxNumber: | 7573370165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2020 | ||||||||
| LastUpdateDate: | 07/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | VA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.