Provider Demographics
NPI:1780635524
Name:HAMBERGER, LARRY KEVIN (PHD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:KEVIN
Last Name:HAMBERGER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:MR
Other - First Name:L
Other - Middle Name:KEVIN
Other - Last Name:HAMBERGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2400 W VILLARD AVE
Mailing Address - Street 2:WFHC GLENDALE FAMILY CENTER
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4901
Mailing Address - Country:US
Mailing Address - Phone:414-527-8458
Mailing Address - Fax:414-527-8045
Practice Address - Street 1:2400 W VILLARD AVE
Practice Address - Street 2:WFHC GLENDALE FAMILY CENTER
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-4901
Practice Address - Country:US
Practice Address - Phone:414-527-8458
Practice Address - Fax:414-527-8045
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1004103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
002000119LOtherHUMANA
WI1780635524Medicaid
WI736011480Medicare PIN
WI1780635524Medicaid