Provider Demographics
NPI:1477189546
Name:LANE, BREONNA DELOIS (LCSW)
Entity Type:Individual
Prefix:MS
First Name:BREONNA
Middle Name:DELOIS
Last Name:LANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1634 PLEXOR LN
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-7285
Mailing Address - Country:US
Mailing Address - Phone:910-315-9479
Mailing Address - Fax:
Practice Address - Street 1:1634 PLEXOR LN
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7285
Practice Address - Country:US
Practice Address - Phone:910-315-9479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0155581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1477189546Medicaid