Provider Demographics
NPI:1386341089
Name:LANE, LAUREN (LMBT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 WADE HAMPTON BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-4947
Mailing Address - Country:US
Mailing Address - Phone:864-696-6079
Mailing Address - Fax:
Practice Address - Street 1:850 WADE HAMPTON BLVD STE C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-4947
Practice Address - Country:US
Practice Address - Phone:864-696-6079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12711225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist