Provider Demographics
NPI:1215036884
Name:CARDASSI, LAWRENCE (PHD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:CARDASSI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:LAWRENCE
Other - Middle Name:
Other - Last Name:CARDASSI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:11803 W NORTH AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2077
Mailing Address - Country:US
Mailing Address - Phone:414-259-0205
Mailing Address - Fax:414-259-0212
Practice Address - Street 1:11803 W NORTH AVE STE 209
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2077
Practice Address - Country:US
Practice Address - Phone:414-259-0205
Practice Address - Fax:414-259-0212
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1828-125103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43571100Medicaid