Provider Demographics
NPI:1609014380
Name:LANE, TERESA LYNN
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:LYNN
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 1:1137 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-541-5190
Mailing Address - Fax:530-541-6031
Practice Address - Street 1:1137 EMERALD BAY RD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6207
Practice Address - Country:US
Practice Address - Phone:530-541-5190
Practice Address - Fax:530-541-6031
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-03
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB4608233101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)