Provider Demographics
NPI:1841333028
Name:LANE, SUSAN (MS, LMFT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4441
Mailing Address - Country:US
Mailing Address - Phone:407-492-6433
Mailing Address - Fax:
Practice Address - Street 1:501 N WYMORE RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2808
Practice Address - Country:US
Practice Address - Phone:407-975-2565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMFT 2121106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist