=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366510117
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLENE LANE PH.D.,LCSWR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2006
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 CRUMS MILL ROAD SUITE 200
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-768-3662
-----------------------------------------------------
Fax | 516-872-1138
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 CRUMS MILLS ROAD SUITE 200
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-768-3662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CW019009
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | R050052
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------