Provider Demographics
NPI:1619485349
Name:LANE, KIMBERLY (LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 FOSSIL CRK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-3009
Mailing Address - Country:US
Mailing Address - Phone:210-865-5263
Mailing Address - Fax:
Practice Address - Street 1:540 MADISON OAK DR STE 340
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3921
Practice Address - Country:US
Practice Address - Phone:210-789-7683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74853101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional