Healthcare Provider Details

I. General information

NPI: 1275122855
Provider Name (Legal Business Name): ALICIA GAIL LANE MSW STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2021
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 QUARRIER ST STE 310
CHARLESTON WV
25301-2338
US

IV. Provider business mailing address

185 POPLAR ESTATES DR
SCOTT DEPOT WV
25560-7268
US

V. Phone/Fax

Practice location:
  • Phone: 304-513-3900
  • Fax:
Mailing address:
  • Phone: 304-859-0350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: