Provider Demographics
NPI:1700068749
Name:LANE, PAMELA J (MED, LPC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:LANE
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9305
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77842-9305
Mailing Address - Country:US
Mailing Address - Phone:979-220-2906
Mailing Address - Fax:
Practice Address - Street 1:6862 BENDWOOD
Practice Address - Street 2:(HOME OFFICE)
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-3769
Practice Address - Country:US
Practice Address - Phone:979-220-2906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-01
Last Update Date:2009-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18017101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1550972-01Medicaid