Provider Demographics
NPI:1255874863
Name:LANE, LACREISHA (QASP)
Entity type:Individual
Prefix:
First Name:LACREISHA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:QASP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 FORTUNE PKWY
Mailing Address - Street 2:SUITE 903
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6746
Mailing Address - Country:US
Mailing Address - Phone:904-538-0713
Mailing Address - Fax:904-538-0714
Practice Address - Street 1:624 PONDER PLACE DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3343
Practice Address - Country:US
Practice Address - Phone:904-863-9699
Practice Address - Fax:706-863-9263
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GARBT-16-20579106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician