=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750615167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA JOY LANE LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2009
-----------------------------------------------------
Last Update Date | 01/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1910 UNIVERSITY DR
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83725-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-426-2869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2691 NW 13TH ST
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-420-5918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LCPC 4906
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------