Provider Demographics
NPI:1124627633
Name:LANE, ANGELA (LCSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:WIESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:639 KINLEY AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1282
Mailing Address - Country:US
Mailing Address - Phone:505-948-0763
Mailing Address - Fax:
Practice Address - Street 1:901 RIO GRANDE BLVD NW STE G252
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-2050
Practice Address - Country:US
Practice Address - Phone:505-585-1570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-113821041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool