Provider Demographics
NPI:1831804681
Name:LANE, HAZEL LAVERN (PSYD)
Entity type:Individual
Prefix:
First Name:HAZEL
Middle Name:LAVERN
Last Name:LANE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15115 CARTWRIGHT TRL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-4685
Mailing Address - Country:US
Mailing Address - Phone:210-861-8429
Mailing Address - Fax:
Practice Address - Street 1:9939 STATE HIGHWAY 151
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-1900
Practice Address - Country:US
Practice Address - Phone:210-861-8429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36266103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling