Provider Demographics
NPI:1275613556
Name:LANE, KIRA C (LPC3502)
Entity Type:Individual
Prefix:MRS
First Name:KIRA
Middle Name:C
Last Name:LANE
Suffix:
Gender:F
Credentials:LPC3502
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 PINE ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4124
Mailing Address - Country:US
Mailing Address - Phone:208-227-6609
Mailing Address - Fax:208-522-8725
Practice Address - Street 1:496 A ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3617
Practice Address - Country:US
Practice Address - Phone:208-552-7100
Practice Address - Fax:208-552-7101
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC3502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDX6889OtherBLUE CROSS OF IDAHO
ID000010156986OtherBLUE SHIELD OF IDAHO