Healthcare Provider Details

I. General information

NPI: 1457729436
Provider Name (Legal Business Name): BETSY LANE LPC, CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 ANNEX RD
JEFFERSON WI
53549-9803
US

IV. Provider business mailing address

1541 ANNEX RD
JEFFERSON WI
53549-9803
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-3105
  • Fax:
Mailing address:
  • Phone: 920-674-3105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17042-132
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7641-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: