Healthcare Provider Details

I. General information

NPI: 1184322091
Provider Name (Legal Business Name): KEVIN LANE LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2061 NW 21ST TER
STUART FL
34994-8839
US

IV. Provider business mailing address

2061 NW 21ST TER APT 102
STUART FL
34994-8839
US

V. Phone/Fax

Practice location:
  • Phone: 772-208-9454
  • Fax:
Mailing address:
  • Phone: 561-252-4971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number21630
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: