Provider Demographics
NPI:1255361002
Name:MANDT, LAWRENCE J (PHD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:J
Last Name:MANDT
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:S88W25730 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-9609
Mailing Address - Country:US
Mailing Address - Phone:262-706-3391
Mailing Address - Fax:
Practice Address - Street 1:2254 MONROE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1902
Practice Address - Country:US
Practice Address - Phone:608-223-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1610103TC0700X
WI1610-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39088600Medicaid
WI1011078OtherPHYSICIANS PLUS ID NUMBER