Provider Demographics
NPI:1083707632
Name:LANE, SYLVIA (PSYD,)
Entity Type:Individual
Prefix:
First Name:SYLVIA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:PSYD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 N WALL ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1735
Mailing Address - Country:US
Mailing Address - Phone:773-551-7536
Mailing Address - Fax:
Practice Address - Street 1:810 N WALL ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1735
Practice Address - Country:US
Practice Address - Phone:773-551-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007520103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical