Healthcare Provider Details

I. General information

NPI: 1396247458
Provider Name (Legal Business Name): REBECCA ELIZABETH LANE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 E COTTONWOOD ST
COTTONWOOD AZ
86326-4382
US

IV. Provider business mailing address

8 E COTTONWOOD ST
COTTONWOOD AZ
86326-4382
US

V. Phone/Fax

Practice location:
  • Phone: 776-347-3338
  • Fax: 866-984-3891
Mailing address:
  • Phone: 778-634-7333
  • Fax: 866-984-3891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number17190
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: