Healthcare Provider Details

I. General information

NPI: 1770611493
Provider Name (Legal Business Name): GLORIA LANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 PARKSIDE DR
COLORADO SPRINGS CO
80910-3130
US

IV. Provider business mailing address

220 RUSKIN DR
COLORADO SPRINGS CO
80910-2522
US

V. Phone/Fax

Practice location:
  • Phone: 719-572-6340
  • Fax: 719-447-4791
Mailing address:
  • Phone: 719-572-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6192
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4561
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: