Provider Demographics
NPI:1215213186
Name:LANTZ, KRYSTAL L (LCP)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:L
Last Name:LANTZ
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:MS
Other - First Name:KRYSTAL
Other - Middle Name:L
Other - Last Name:HERGOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMLP
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66505-0747
Mailing Address - Country:US
Mailing Address - Phone:785-587-4300
Mailing Address - Fax:785-587-4377
Practice Address - Street 1:1558 HAYES DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502
Practice Address - Country:US
Practice Address - Phone:785-587-4315
Practice Address - Fax:785-587-4377
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1402103TC0700X
KS1460101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200742900BMedicaid