Provider Demographics
NPI:1629583166
Name:LANE, BEVERLY CLAIRE (LCSW)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:CLAIRE
Last Name:LANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CLAIRE
Other - Middle Name:
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1136 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6439
Mailing Address - Country:US
Mailing Address - Phone:910-833-5902
Mailing Address - Fax:910-833-5905
Practice Address - Street 1:1136 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-6439
Practice Address - Country:US
Practice Address - Phone:910-833-5902
Practice Address - Fax:910-833-5905
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0087021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty