Basic Information
| Provider Information | |||||||||
| NPI: | 1558952663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | ABIGAIL | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | LMHC, CASAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4141 BIRCHWOOD DR N | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130902101 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 113 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | NORTH SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132122370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154150308 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2021 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 32842 | NY | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 010623-01 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.