Provider Demographics
NPI:1831870815
Name:LANE, MYIA CORMICHEL (LCSW)
Entity type:Individual
Prefix:MS
First Name:MYIA
Middle Name:CORMICHEL
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 1:69 HOLLY CIR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-8629
Mailing Address - Country:US
Mailing Address - Phone:228-219-5219
Mailing Address - Fax:
Practice Address - Street 1:4605 GOLDFINCH DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-7218
Practice Address - Country:US
Practice Address - Phone:228-219-5219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM9748101Y00000X
MSC111171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor