Individual
ETHAN DWIGHT LANTZ
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
6020 BROADWAY ST, QUINCY, IL 62305-7919
(217) 224-3366
Mailing address
6020 BROADWAY ST, QUINCY, IL 62305-7919
(217) 224-3366
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
071.010740
IL
Other
Enumeration date
03/30/2022
Last updated
03/30/2022
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