Provider Demographics
NPI:1316572688
Name:LANE, SHYRIDA DANESS
Entity Type:Individual
Prefix:
First Name:SHYRIDA
Middle Name:DANESS
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 1:9381 N 49TH ST APT 102
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-6429
Mailing Address - Country:US
Mailing Address - Phone:414-499-4220
Mailing Address - Fax:
Practice Address - Street 1:1730 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-1254
Practice Address - Country:US
Practice Address - Phone:414-906-2714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-07
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19075-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)