Provider Demographics
NPI:1083730816
Name:LANTZY, COLLEEN E (MA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:E
Last Name:LANTZY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 N 124TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4609
Mailing Address - Country:US
Mailing Address - Phone:262-641-4347
Mailing Address - Fax:262-641-4350
Practice Address - Street 1:2515 N 124TH ST STE 101
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4609
Practice Address - Country:US
Practice Address - Phone:262-641-4347
Practice Address - Fax:262-641-4350
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI692-125101YP2500X
WI45-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional