Provider Demographics
NPI:1639189608
Name:LANZE, MARK CARL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CARL
Last Name:LANZE
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 1:8265 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4115
Mailing Address - Country:US
Mailing Address - Phone:716-634-6757
Mailing Address - Fax:716-634-9297
Practice Address - Street 1:8265 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-4115
Practice Address - Country:US
Practice Address - Phone:716-634-6757
Practice Address - Fax:716-634-9297
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012216103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01823963Medicaid
NY11475BMedicare ID - Type Unspecified