Provider Demographics
NPI:1215510011
Name:LANE, MORIAH R (LCSW)
Entity type:Individual
Prefix:MS
First Name:MORIAH
Middle Name:R
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 1:29A EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-2556
Mailing Address - Country:US
Mailing Address - Phone:978-675-9500
Mailing Address - Fax:
Practice Address - Street 1:29A EMERSON AVE
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-2556
Practice Address - Country:US
Practice Address - Phone:978-675-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225003104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA22503OtherLICENSED CERTIFIED SOCIAL WORKER