Provider Demographics
NPI:1497438568
Name:LANE, STEPHANIE JOANN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JOANN
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 1:608 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-4204
Mailing Address - Country:US
Mailing Address - Phone:419-834-4880
Mailing Address - Fax:
Practice Address - Street 1:608 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-4204
Practice Address - Country:US
Practice Address - Phone:419-834-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA185382101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)