Provider Demographics
NPI:1427412360
Name:THEODORE W. LANE PHD, PLLC
Entity Type:Organization
Organization Name:THEODORE W. LANE PHD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:W
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-692-9100
Mailing Address - Street 1:185 E NEW HAMPSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5529
Mailing Address - Country:US
Mailing Address - Phone:910-692-9100
Mailing Address - Fax:910-692-9109
Practice Address - Street 1:185 E NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5529
Practice Address - Country:US
Practice Address - Phone:910-692-9100
Practice Address - Fax:910-692-9109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1264103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty