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General NPI Number Information
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NPI Number | 1255361002
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Entity Type | Individual
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Provider Name | LAWRENCE J MANDT PH.D.
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Gender | Male
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Dates
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Enumeration Date | 07/04/2006
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Last Update Date | 08/09/2023
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Provider Practice Location Address
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Address Line | 2254 MONROE ST
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City | MADISON
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State | WI
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Zip | 53711-1902
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Country | US
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Telephone | 608-223-9767
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Fax |
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Provider Business Mailing Address
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Address Line | S88W25730 EDGEWOOD AVE
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City | MUKWONAGO
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State | WI
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Zip | 53149-9609
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Country | US
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Telephone | 262-706-3391
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1610
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1610-57
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License Number State | WI
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