Healthcare Provider Details

I. General information

NPI: 1174560627
Provider Name (Legal Business Name): LARRY J LANTINGA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 IRVING AVE
SYRACUSE NY
13210-2716
US

IV. Provider business mailing address

63 CHAPEL WOODS W
WILLIAMSVILLE NY
14221-1851
US

V. Phone/Fax

Practice location:
  • Phone: 315-425-3487
  • Fax: 315-425-3447
Mailing address:
  • Phone: 716-639-0657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number007331-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: