Provider Demographics
NPI:1750615167
Name:LANE, KRISTA JOY (LCPC)
Entity type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:JOY
Last Name:LANE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2691 NW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3102
Mailing Address - Country:US
Mailing Address - Phone:208-420-5918
Mailing Address - Fax:
Practice Address - Street 1:1910 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-5047
Practice Address - Country:US
Practice Address - Phone:208-426-2869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC 4906101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional