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General NPI Number Information
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NPI Number | 1942301056
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Entity Type | Individual
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Provider Name | SANDRA JO LANE LCSW, BCD, CGP
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Gender | Female
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Dates
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Enumeration Date | 09/25/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 627 HALF HOLLOW RD
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City | DIX HILLS
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State | NY
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Zip | 11746-6233
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Country | US
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Telephone | 631-586-7429
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Fax | 631-254-1228
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Provider Business Mailing Address
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Address Line | 627 HALF HOLLOW RD
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City | DIX HILLS
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State | NY
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Zip | 11746-6233
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Country | US
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Telephone | 631-586-7429
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Fax | 631-254-1228
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | NYSR28454
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License Number State | NY
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