MEDICARE: DR. CAREY E LAINE PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	PSY 21635	CA
2	103TE1100X	Exercise & Sports Psychologist	PSY 21635	CA
3	103TF0000X	Family Psychologist	PSY 21635	CA
4	103TC0700X	Clinical Psychologist	PSY 21635	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OPL 216 350	OTHER	CA	BLUE SHIELD
2	12290214	OTHER	CA	CAQH

General Provider Information

NPI Number	:	1205834058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAREY E LAINE PSY.D.

Provider Business Mailing Address
First Line	:	PO BOX 1288
Second Line	:
City	:	NEVADA CITY
State	:	CA
Zip	:	95959-1288
Country	:	US
Telephone Number	:	530-277-0976
Fax Number	:	833-900-1392

Provider Business Practice Location Address
First Line	:	11327 WILLOW VALLEY RD
Second Line	:	STE A
City	:	NEVADA CITY
State	:	CA
Zip	:	95959-8623
Country	:	US
Telephone Number	:	530-277-0976
Fax Number	:	833-900-1392

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	12/04/2019

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