Healthcare Provider Details

I. General information

NPI: 1578582904
Provider Name (Legal Business Name): LANE STEPHENSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 GRANDVIEW DR
BROOKSVILLE KY
41004-8213
US

IV. Provider business mailing address

611 FOREST AVE
MAYSVILLE KY
41056-1411
US

V. Phone/Fax

Practice location:
  • Phone: 606-735-3611
  • Fax: 606-735-2581
Mailing address:
  • Phone: 606-564-4016
  • Fax: 606-564-8288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number394
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: