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General NPI Number Information
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NPI Number | 1427412360
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Entity Type | Organization
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Legal Business Name | THEODORE W. LANE PHD, PLLC
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Dates
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Enumeration Date | 04/06/2016
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Last Update Date | 04/06/2016
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Provider Practice Location Address
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Address Line | 185 E NEW HAMPSHIRE AVE
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City | SOUTHERN PINES
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State | NC
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Zip | 28387-5529
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Country | US
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Telephone | 910-692-9100
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Fax | 910-692-9109
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Provider Business Mailing Address
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Address Line | 185 E NEW HAMPSHIRE AVE
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City | SOUTHERN PINES
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State | NC
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Zip | 28387-5529
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Country | US
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Telephone | 910-692-9100
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Fax | 910-692-9109
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. THEODORE W LANE
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Credential | PH.D.
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Telephone | 910-692-9100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1264
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License Number State | NC
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