Provider Demographics
NPI:1457691883
Name:LANE, STACEY MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:LANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 PIONEER AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3024
Mailing Address - Country:US
Mailing Address - Phone:307-287-7685
Mailing Address - Fax:307-248-5600
Practice Address - Street 1:2622 PIONEER AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3024
Practice Address - Country:US
Practice Address - Phone:307-287-7685
Practice Address - Fax:307-248-5600
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9321041C0700X, 1041C0700X
WY5431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical