Provider Demographics
NPI:1275064941
Name:LANE, ALEXIS NCOLE
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NCOLE
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 1:1524 PENSACOLA ST APT 304
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-3834
Mailing Address - Country:US
Mailing Address - Phone:206-291-0978
Mailing Address - Fax:
Practice Address - Street 1:1524 PENSACOLA ST APT 304
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96822-3834
Practice Address - Country:US
Practice Address - Phone:206-291-0978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI106S00000X
HIMHC894101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician