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NPI Code Detail

MEDICARE: KELLY LANE LMHC

MEDICARE: KELLY LANE LMHC
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
1101YM0800XMental Health Counselor16685FL

General Provider Information

NPI Number : 1225594005
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY LANE LMHC
Provider Business Mailing Address
First Line : 3705 HARROGATE DR
Second Line :
City : VALRICO
State : FL
Zip : 33596-8401
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 7821 N DALE MABRY HWY
Second Line :
City : TAMPA
State : FL
Zip : 33614-3275
Country : US
Telephone Number : 813-443-4827
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/16/2019
Last Update Date : 02/16/2019

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