Provider Demographics
NPI:1902910607
Name:LIGUORI, LAURA CHARLENE (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CHARLENE
Last Name:LIGUORI
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 1:2600 N MAYFAIR RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-257-0233
Mailing Address - Fax:414-257-3588
Practice Address - Street 1:250 N SUNNY SLOPE RD
Practice Address - Street 2:SUITE 290
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4809
Practice Address - Country:US
Practice Address - Phone:262-754-9460
Practice Address - Fax:262-754-9468
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2461-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40913500Medicaid
WI000044354Medicare ID - Type UnspecifiedMEDICARE PROVIDER #