Provider Demographics
NPI:1104012244
Name:LAURI GEBHARD
Entity Type:Organization
Organization Name:LAURI GEBHARD
Other - Org Name:MIND-BODY PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST, DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:GEBHARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-407-6664
Mailing Address - Street 1:10855 W POTTER RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3439
Mailing Address - Country:US
Mailing Address - Phone:414-407-6664
Mailing Address - Fax:414-302-1339
Practice Address - Street 1:10855 W POTTER RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3439
Practice Address - Country:US
Practice Address - Phone:414-407-6664
Practice Address - Fax:414-302-1330
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAURI GEBHARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-22
Last Update Date:2007-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2028103T00000X, 103TB0200X, 103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39121000Medicaid
WI39121000Medicaid