Provider Demographics
NPI:1578506705
Name:LANE, SUSAN (LPCC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 RIO GRANDE BLVD NW
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-2633
Mailing Address - Country:US
Mailing Address - Phone:505-830-1200
Mailing Address - Fax:505-830-1203
Practice Address - Street 1:1306 RIO GRANDE BLVD NW
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-2633
Practice Address - Country:US
Practice Address - Phone:505-830-1200
Practice Address - Fax:505-830-1203
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0088191101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0088191Medicaid