Healthcare Provider Details

I. General information

NPI: 1952470668
Provider Name (Legal Business Name): THOMAS J. LANTSBERGER, PH.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14561 NORTH OUTER 40 ROAD SUITE 250
CHESTERFIELD MO
63017
US

IV. Provider business mailing address

14561 NORTH OUTER 40 ROAD SUITE 250
CHESTERFIELD MO
63017
US

V. Phone/Fax

Practice location:
  • Phone: 314-881-4260
  • Fax: 314-881-4262
Mailing address:
  • Phone: 314-881-4260
  • Fax: 314-881-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberM001687
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number01687
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMO0004978
License Number StateMO

VIII. Authorized Official

Name: MS. MELISSA M. LANTSBERGER
Title or Position: OFFICE MANAGER
Credential: M.S.
Phone: 314-881-4260