Provider Demographics
NPI:1154597771
Name:LARDINOIS, PHYLLIS ANN (MA, LPC)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:ANN
Last Name:LARDINOIS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12308 W DIANE DR
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3359
Mailing Address - Country:US
Mailing Address - Phone:414-614-9204
Mailing Address - Fax:
Practice Address - Street 1:3200 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3252
Practice Address - Country:US
Practice Address - Phone:414-614-9204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-04
Last Update Date:2008-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1627125101YP2500X
WIL635000118158101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI26-1704319OtherINTERNAL REVENUE SERVICE