Healthcare Provider Details

I. General information

NPI: 1386258622
Provider Name (Legal Business Name): ANN LANTAGNE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 E 16TH AVE
AURORA CO
80045-7106
US

IV. Provider business mailing address

PO BOX 110429
AURORA CO
80042-0429
US

V. Phone/Fax

Practice location:
  • Phone: 720-777-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY.0005358
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPSY.0005358
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY.0005358
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: