Healthcare Provider Details

I. General information

NPI: 1992237176
Provider Name (Legal Business Name): LAUREN MARIE GOLLA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 N BILTMORE LN
MADISON WI
53718-2161
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-592-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301017819
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301017819
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number6301017819
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number21123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: