MEDICARE: MS. SHELBY NICOLE LANE LCSW-A

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	1041C0700X	Clinical Social Worker	P008332	NC

General Provider Information

NPI Number	:	1245660679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHELBY NICOLE LANE LCSW-A

Provider Business Mailing Address
First Line	:	807 E MAIN ST
Second Line	:	SUITE 2-120
City	:	DURHAM
State	:	NC
Zip	:	27701-4074
Country	:	US
Telephone Number	:	919-682-5300
Fax Number	:	919-682-5322

Provider Business Practice Location Address
First Line	:	807 E MAIN ST
Second Line	:	SUITE 2-120
City	:	DURHAM
State	:	NC
Zip	:	27701-4074
Country	:	US
Telephone Number	:	919-682-5300
Fax Number	:	919-682-5322

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

Provider Enumeration Date	:	11/21/2013
Last Update Date	:	11/22/2013

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