Provider Demographics
NPI:1659979581
Name:LANE, CHASERIE SYMONE
Entity Type:Individual
Prefix:
First Name:CHASERIE
Middle Name:SYMONE
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 1:4389 BIRMINGHAM LN APT 305
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-2034
Mailing Address - Country:US
Mailing Address - Phone:901-871-7374
Mailing Address - Fax:
Practice Address - Street 1:3875 TIGER PAW ST S
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152-3920
Practice Address - Country:US
Practice Address - Phone:901-678-5059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20-139605106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician