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General NPI Number Information
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NPI Number | 1265554430
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Entity Type | Organization
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Legal Business Name | ELKHART PSYCHOLOGICAL SERVICES, LLC
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Dates
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Enumeration Date | 04/06/2007
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 6000 MONONA DR SUITE 203
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City | MONONA
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State | WI
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Zip | 53716-3931
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Country | US
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Telephone | 608-223-9767
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Fax | 608-223-9767
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Provider Business Mailing Address
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Address Line | 6000 MONONA DR SUITE 203
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City | MONONA
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State | WI
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Zip | 53716-3931
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Country | US
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Telephone | 608-223-9767
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Fax | 608-223-9767
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Authorized Official
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Title or Position | OWNER
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Name | DR. LAWRENCE MANDT
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Credential | PH.D
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Telephone | 608-223-9767
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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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