Provider Demographics
NPI:1205834058
Name:LAINE, CAREY E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CAREY
Middle Name:E
Last Name:LAINE
Suffix:
Gender:M
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:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-1288
Mailing Address - Country:US
Mailing Address - Phone:530-277-0976
Mailing Address - Fax:833-900-1392
Practice Address - Street 1:11327 WILLOW VALLEY RD
Practice Address - Street 2:STE A
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-8623
Practice Address - Country:US
Practice Address - Phone:530-277-0976
Practice Address - Fax:833-900-1392
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21635103TC2200X, 103TE1100X, 103TF0000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL 216 350OtherBLUE SHIELD
CA12290214OtherCAQH
CAOPL 216 350OtherBLUE SHIELD