Provider Demographics
NPI:1316731227
Name:LANE, ANGELIQUE MONICA (SUDPT)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:MONICA
Last Name:LANE
Suffix:
Gender:
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 BISHOP RD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-8746
Mailing Address - Country:US
Mailing Address - Phone:360-431-1552
Mailing Address - Fax:
Practice Address - Street 1:2708 WESTMOOR CT SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5754
Practice Address - Country:US
Practice Address - Phone:360-943-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61655108101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)