Provider Demographics
NPI:1629228879
Name:BERENDT, LAURIE ELLEN (MS CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:ELLEN
Last Name:BERENDT
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:MISS
Other - First Name:LAURIE
Other - Middle Name:ELLEN
Other - Last Name:LUKAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1755 N BARKER ROAD
Mailing Address - Street 2:CARE - AGE OF BROOKFIELD
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-1835
Mailing Address - Country:US
Mailing Address - Phone:262-821-3939
Mailing Address - Fax:262-821-3944
Practice Address - Street 1:1755 N BARKER ROAD
Practice Address - Street 2:CARE - AGE OF BROOKFIELD
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-1835
Practice Address - Country:US
Practice Address - Phone:262-821-3939
Practice Address - Fax:262-821-3944
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1159-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42728400Medicaid