Provider Demographics
NPI:1215028311
Name:STAVA, LAWRENCE JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:JAMES
Last Name:STAVA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 W MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-2849
Mailing Address - Country:US
Mailing Address - Phone:608-825-6663
Mailing Address - Fax:608-825-6946
Practice Address - Street 1:705 W MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-2849
Practice Address - Country:US
Practice Address - Phone:608-825-6663
Practice Address - Fax:608-825-6946
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI966-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1011066OtherPHYSICIAN PLUS INSURANCE
WI39030200Medicaid
WI39172774704OtherUNITY HEALTH PLAN
WI1011066OtherPHYSICIAN PLUS INSURANCE