Provider Demographics
NPI:1578641569
Name:LANE, LAURA L (LCSW)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:L
Last Name:LANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:MO
Mailing Address - Zip Code:64424-1770
Mailing Address - Country:US
Mailing Address - Phone:660-425-4155
Mailing Address - Fax:660-425-4155
Practice Address - Street 1:2600 MILLER ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-2701
Practice Address - Country:US
Practice Address - Phone:660-425-0303
Practice Address - Fax:660-425-8235
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030096821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ40438Medicare UPIN
MOB64D743Medicare ID - Type Unspecified