Healthcare Provider Details

I. General information

NPI: 1427166628
Provider Name (Legal Business Name): BETTIE JANE LARUS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: B J CZISNY

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 DEWEY AVE
MILWAUKEE WI
53213
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 414-454-6707
  • Fax: 414-454-6747
Mailing address:
  • Phone: 414-647-6326
  • Fax: 414-671-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number53445-030
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2380-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: