Healthcare Provider Details

I. General information

NPI: 1407979206
Provider Name (Legal Business Name): WILLIAM DAVID LAAKSO PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N ADAMS ST
GREEN BAY WI
54301-5145
US

IV. Provider business mailing address

1211 LIVINGSTON ST
GREEN BAY WI
54311-5547
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-6993
  • Fax:
Mailing address:
  • Phone: 920-468-0726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1890-057
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20040485A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: