Provider Demographics
NPI:1487646436
Name:MIRHOSEINI, LAURA TOORAN (PSY D)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:TOORAN
Last Name:MIRHOSEINI
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 GARDNER AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-2160
Mailing Address - Country:US
Mailing Address - Phone:262-763-7766
Mailing Address - Fax:262-763-9326
Practice Address - Street 1:190 GARDNER AVE STE 3
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-2160
Practice Address - Country:US
Practice Address - Phone:262-763-7766
Practice Address - Fax:262-763-9326
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2509-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39145800Medicaid