Provider Demographics
NPI:1902358120
Name:BJUSTROM, LAURIE DONNELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:DONNELL
Last Name:BJUSTROM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 FORSETH DR
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-2279
Mailing Address - Country:US
Mailing Address - Phone:414-333-5816
Mailing Address - Fax:
Practice Address - Street 1:741 N GRAND AVE STE 302
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4841
Practice Address - Country:US
Practice Address - Phone:292-789-1191
Practice Address - Fax:262-542-0823
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3417-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100062371Medicaid