Healthcare Provider Details

I. General information

NPI: 1194770354
Provider Name (Legal Business Name): CHRISTINE L. LANE LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W MONROE ST SUITE 307 MAILBOX 14
BLOOMINGTON IL
61701-3997
US

IV. Provider business mailing address

200 W MONROE ST SUITE 307 MAILBOX 14
BLOOMINGTON IL
61701-3997
US

V. Phone/Fax

Practice location:
  • Phone: 309-829-2600
  • Fax:
Mailing address:
  • Phone: 309-829-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: