Basic Information
| Provider Information | |||||||||
| NPI: | 1386954907 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LANSING INSTITUTE OF BEHAVIORAL MEDICINE, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIFESTANCE HEALTH, INC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3475 BELLE CHASE WAY | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489114252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178823732 | ||||||||
| FaxNumber: | 5178823633 | ||||||||
| Practice Location | |||||||||
| Address1: | 3475 BELLE CHASE WAY | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489114252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178823732 | ||||||||
| FaxNumber: | 5178823633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2010 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONRAD | ||||||||
| AuthorizedOfficialFirstName: | KRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | DORRENE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5178823732 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.