Provider Demographics
NPI:1134100068
Name:LACOCQUE, DAVID E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:E
Last Name:LACOCQUE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:E
Other - Last Name:LACOCQUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:702 N BLACKHAWK AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3357
Mailing Address - Country:US
Mailing Address - Phone:608-358-6868
Mailing Address - Fax:608-441-3370
Practice Address - Street 1:222 S BEDFORD ST
Practice Address - Street 2:ISTHMUS PSYCHOTHERAPY, LLC
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-3688
Practice Address - Country:US
Practice Address - Phone:608-256-6570
Practice Address - Fax:608-256-4551
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2397057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39140500Medicaid