Provider Demographics
NPI:1699233296
Name:LANE, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 MORSE ST
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-2829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 S MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27110-6300
Practice Address - Country:US
Practice Address - Phone:336-750-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2021-07-06
Deactivation Date:2020-09-08
Deactivation Code:
Reactivation Date:2020-10-21
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist