=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831804681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAZEL LAVERN LANE PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2023
-----------------------------------------------------
Last Update Date | 01/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9939 STATE HIGHWAY 151
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78251-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-861-8429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15115 CARTWRIGHT TRL
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78253-4685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-861-8429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 36266
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------