Provider Demographics
NPI:1801959564
Name:LANE, TERESA (LISW AP CP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LISW AP CP
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:LIPSCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2919 MOSS BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-3593
Mailing Address - Country:US
Mailing Address - Phone:843-457-1615
Mailing Address - Fax:
Practice Address - Street 1:1107 48TH AVE N STE 310F
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5443
Practice Address - Country:US
Practice Address - Phone:843-457-1615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-17
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical