Provider Demographics
NPI:1578347621
Name:LANE, SAMANTHA COLLEEN (LCSW, LMSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:COLLEEN
Last Name:LANE
Suffix:
Gender:F
Credentials:LCSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 VANN RD
Mailing Address - Street 2:
Mailing Address - City:SMITHS
Mailing Address - State:AL
Mailing Address - Zip Code:36877-2276
Mailing Address - Country:US
Mailing Address - Phone:575-342-8009
Mailing Address - Fax:
Practice Address - Street 1:616 VANN RD
Practice Address - Street 2:
Practice Address - City:SMITHS
Practice Address - State:AL
Practice Address - Zip Code:36877-2276
Practice Address - Country:US
Practice Address - Phone:575-342-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104100000X
TX1051271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker