Healthcare Provider Details

I. General information

NPI: 1982567657
Provider Name (Legal Business Name): MADELEINE R LANE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 12085
DURHAM NC
27709-2085
US

IV. Provider business mailing address

PO BOX 12085
DURHAM NC
27709-2085
US

V. Phone/Fax

Practice location:
  • Phone: 224-210-4874
  • Fax:
Mailing address:
  • Phone: 224-210-4874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20044018A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: