Basic Information
Provider Information | |||||||||
NPI: | 1881978328 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LANE | ||||||||
FirstName: | CELESTE | ||||||||
MiddleName: | KATHLEEN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STEVENS | ||||||||
OtherFirstName: | CELESTE | ||||||||
OtherMiddleName: | KATHLEEN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSW/ASW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 790 E BONITA AVE | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917671906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9096257207 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 790 E BONITA AVE | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917671906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9096257207 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2011 | ||||||||
LastUpdateDate: | 09/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW68508 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.