1902910607 NPI number — LAURA CHARLENE LIGUORI PH.D.

Table of content: LAURA CHARLENE LIGUORI PH.D. (NPI 1902910607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902910607 NPI number — LAURA CHARLENE LIGUORI PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIGUORI
Provider First Name:
LAURA
Provider Middle Name:
CHARLENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902910607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 N MAYFAIR RD
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-257-0233
Provider Business Mailing Address Fax Number:
414-257-3588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 N SUNNY SLOPE RD
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53005-4809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-754-9460
Provider Business Practice Location Address Fax Number:
262-754-9468
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2461-057 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40913500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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