Provider Demographics
NPI:1457427239
Name:MAUCIERI, LAWRENCE PAUL JR (PHD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:PAUL
Last Name:MAUCIERI
Suffix:JR
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 1:640 W SHERIDAN RD
Mailing Address - Street 2:APARTMENT 409
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3320
Mailing Address - Country:US
Mailing Address - Phone:773-401-9831
Mailing Address - Fax:
Practice Address - Street 1:203 N WABASH AVE
Practice Address - Street 2:SUITE 2106
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-2406
Practice Address - Country:US
Practice Address - Phone:773-401-9831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1635586OtherBLUE CROSS BLUE SHIELD
IL1635586OtherBLUE CROSS BLUE SHIELD