Provider Demographics
NPI:1417325846
Name:LANE, DESIREE AMBER
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:AMBER
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:PO BOX 138
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720
Mailing Address - Country:US
Mailing Address - Phone:541-573-7303
Mailing Address - Fax:541-573-5938
Practice Address - Street 1:705 HIGHWAY 20 SOUTH
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:OR
Practice Address - Zip Code:97738
Practice Address - Country:US
Practice Address - Phone:541-573-7303
Practice Address - Fax:541-573-5938
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor