Basic Information
| Provider Information | |||||||||
| NPI: | 1215213186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANTZ | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERGOTT | ||||||||
| OtherFirstName: | KRYSTAL | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 747 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665050747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855874300 | ||||||||
| FaxNumber: | 7855874377 | ||||||||
| Practice Location | |||||||||
| Address1: | 1558 HAYES DR | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855874315 | ||||||||
| FaxNumber: | 7855874377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2011 | ||||||||
| LastUpdateDate: | 08/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1402 | KS | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 101YM0800X | 1460 | KS | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 200742900B | 05 | KS | MEDICAID |