Provider Demographics
NPI:1255610325
Name:ANSARI, LORI J (PSYD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:J
Last Name:ANSARI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1808
Mailing Address - Country:US
Mailing Address - Phone:608-524-5151
Mailing Address - Fax:608-524-5353
Practice Address - Street 1:710 N WEBB AVE
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1142
Practice Address - Country:US
Practice Address - Phone:608-524-5151
Practice Address - Fax:608-524-5353
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3014-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical