Provider Demographics
NPI:1174560627
Name:LANTINGA, LARRY J (PHD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:J
Last Name:LANTINGA
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 1:63 CHAPEL WOODS W
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1851
Mailing Address - Country:US
Mailing Address - Phone:716-639-0657
Mailing Address - Fax:
Practice Address - Street 1:800 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2716
Practice Address - Country:US
Practice Address - Phone:315-425-3487
Practice Address - Fax:315-425-3447
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007331-1103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling