Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003182379 |
---|---|
Provider Name | Desarae Margaret Lane |
First Address | Grants Pass, OR 97527-5500 |
Second Address | Grants Pass, OR 97527-5500 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2012 |
Last Update Date | 30/03/2012 |