Provider Demographics
NPI:1700185451
Name:LANE, CHARITY R (PSYD)
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:R
Last Name:LANE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-6565
Mailing Address - Country:US
Mailing Address - Phone:260-494-7037
Mailing Address - Fax:
Practice Address - Street 1:1737 S NAPERVILLE RD
Practice Address - Street 2:WHEATON
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-5894
Practice Address - Country:US
Practice Address - Phone:630-653-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010522103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical