Provider Demographics
NPI:1619663564
Name:LANE, CLARISSA
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
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 1:17285 VETERANS MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:DUNGANNON
Mailing Address - State:VA
Mailing Address - Zip Code:24245-3937
Mailing Address - Country:US
Mailing Address - Phone:276-467-2201
Mailing Address - Fax:276-467-2673
Practice Address - Street 1:17285 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:DUNGANNON
Practice Address - State:VA
Practice Address - Zip Code:24245-3937
Practice Address - Country:US
Practice Address - Phone:276-467-2201
Practice Address - Fax:276-467-2673
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040165781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical