Healthcare Provider Details

I. General information

NPI: 1255361002
Provider Name (Legal Business Name): LAWRENCE J MANDT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2254 MONROE ST
MADISON WI
53711-1902
US

IV. Provider business mailing address

S88W25730 EDGEWOOD AVE
MUKWONAGO WI
53149-9609
US

V. Phone/Fax

Practice location:
  • Phone: 608-223-9767
  • Fax:
Mailing address:
  • Phone: 262-706-3391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1610-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1610
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: