Provider Demographics
NPI:1689984288
Name:LANE, MARSHA TEAGUE (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:MARSHA
Middle Name:TEAGUE
Last Name:LANE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 N WESTSHORE BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-4616
Mailing Address - Country:US
Mailing Address - Phone:813-490-5494
Mailing Address - Fax:
Practice Address - Street 1:1311 N WESTSHORE BLVD STE 302
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-4616
Practice Address - Country:US
Practice Address - Phone:813-490-5494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3104101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767151200Medicaid