Provider Demographics
NPI:1174848022
Name:DEWAN, LANE (PSYD)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:
Last Name:DEWAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11575 SW PACIFIC HWY # 1031
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8671
Mailing Address - Country:US
Mailing Address - Phone:503-395-5122
Mailing Address - Fax:
Practice Address - Street 1:11575 SW PACIFIC HWY # 1031
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8671
Practice Address - Country:US
Practice Address - Phone:503-395-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1949103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical