Healthcare Provider Details

I. General information

NPI: 1265554430
Provider Name (Legal Business Name): ELKHART PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 MONONA DR SUITE 203
MONONA WI
53716-3931
US

IV. Provider business mailing address

6000 MONONA DR SUITE 203
MONONA WI
53716-3931
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1610
License Number StateWI

VIII. Authorized Official

Name: DR. LAWRENCE MANDT
Title or Position: OWNER
Credential: PH.D
Phone: 608-223-9767