Provider Demographics
NPI:1023156932
Name:LANE, THEODORE W (PHD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:W
Last Name:LANE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E CONNECTICUT AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-6719
Mailing Address - Country:US
Mailing Address - Phone:910-692-4624
Mailing Address - Fax:
Practice Address - Street 1:1540 PURDUE DR STE 200
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5510
Practice Address - Country:US
Practice Address - Phone:910-867-8889
Practice Address - Fax:910-487-3061
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1264103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical