Healthcare Provider Details

I. General information

NPI: 1104012244
Provider Name (Legal Business Name): LAURI GEBHARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2007
Last Update Date: 09/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10855 W POTTER RD
WAUWATOSA WI
53226-3439
US

IV. Provider business mailing address

10855 W POTTER RD
WAUWATOSA WI
53226-3439
US

V. Phone/Fax

Practice location:
  • Phone: 414-407-6664
  • Fax: 414-302-1330
Mailing address:
  • Phone: 414-407-6664
  • Fax: 414-302-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2028
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2028
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number2028
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2028
License Number StateWI

VIII. Authorized Official

Name: DR. LAURI CHRISTINE GEBHARD
Title or Position: PSYCHOLOGIST, DIRECTOR
Credential: PH.D
Phone: 414-407-6664