=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124627633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA LANE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2020
-----------------------------------------------------
Last Update Date | 10/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 RIO GRANDE BLVD NW STE G252
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87104-2050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-585-1570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 639 KINLEY AVE NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-1282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-948-0763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | M-11382
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | M-11382
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------