Provider Demographics
NPI:1124452784
Name:LANE, ANGELA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
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 1:6741 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85730-1605
Mailing Address - Country:US
Mailing Address - Phone:520-304-5212
Mailing Address - Fax:
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:520-629-4755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2019-12-16
Deactivation Date:2017-08-09
Deactivation Code:
Reactivation Date:2019-12-13
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-115441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical