Provider Demographics
NPI:1548850043
Name:LANE, WILLECIA (MSW)
Entity type:Individual
Prefix:
First Name:WILLECIA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1996 NORTHPORT RD APT 2
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-3882
Mailing Address - Country:US
Mailing Address - Phone:901-462-4843
Mailing Address - Fax:
Practice Address - Street 1:4646 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4426
Practice Address - Country:US
Practice Address - Phone:901-443-8895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor