Provider Demographics
NPI:1932378908
Name:LANTZ, CONNIE SUE (LCSW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:SUE
Last Name:LANTZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 MATE COURT
Mailing Address - Street 2:
Mailing Address - City:RIO RICO
Mailing Address - State:AZ
Mailing Address - Zip Code:85648-2416
Mailing Address - Country:US
Mailing Address - Phone:520-262-0084
Mailing Address - Fax:
Practice Address - Street 1:1701 W SAINT MARYS RD
Practice Address - Street 2:SUITE 160
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2621
Practice Address - Country:US
Practice Address - Phone:520-262-0084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-124321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ311221OtherAHCCCS