Provider Demographics
NPI:1063020246
Name:LANE, SAMANTHA (LSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5402 APPLEWOOD CLOSE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5490
Mailing Address - Country:US
Mailing Address - Phone:815-601-2555
Mailing Address - Fax:
Practice Address - Street 1:5402 APPLEWOOD CLOSE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5490
Practice Address - Country:US
Practice Address - Phone:815-601-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1045141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical