Provider Demographics
NPI:1003322553
Name:LANE, SHOSHANNA NOELLE
Entity Type:Individual
Prefix:
First Name:SHOSHANNA
Middle Name:NOELLE
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-2756
Mailing Address - Country:US
Mailing Address - Phone:541-772-1777
Mailing Address - Fax:
Practice Address - Street 1:300 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-2756
Practice Address - Country:US
Practice Address - Phone:541-772-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician