Provider Demographics
NPI:1821433525
Name:LAINE, LIA M
Entity Type:Individual
Prefix:MRS
First Name:LIA
Middle Name:M
Last Name:LAINE
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 1:890 ELM GROVE RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:890 ELM GROVE RD
Practice Address - Street 2:VILLAGE COURT BUILDINGS SUITE #205
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2528
Practice Address - Country:US
Practice Address - Phone:262-780-0991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4975-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional