Provider Demographics
NPI:1265509897
Name:LANE, VICKI L (PHD)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:LANE
Suffix:
Gender:F
Credentials:PHD
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 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:1600 W CHANDLER BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6100
Practice Address - Country:US
Practice Address - Phone:415-296-5290
Practice Address - Fax:415-296-5299
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-005255103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000247634OtherANTHEM
IN100437960Medicaid
IN257900LLMedicare PIN
IN533200EMedicare PIN
IN100437960Medicaid