Provider Demographics
NPI:1215278304
Name:LANE, SHANNON (LCSW, CADC)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:
Last Name:LANE
Suffix:
Gender:M
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:682 W BOUGHTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2199
Mailing Address - Country:US
Mailing Address - Phone:630-945-0429
Mailing Address - Fax:
Practice Address - Street 1:682 W BOUGHTON RD STE B
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2199
Practice Address - Country:US
Practice Address - Phone:630-945-0429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL28818101YA0400X
IL149.0151751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)