Provider Demographics
NPI:1922045970
Name:GREEN, LAURI THERESA (MD)
Entity type:Individual
Prefix:
First Name:LAURI
Middle Name:THERESA
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1177 QUAIL CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3790
Mailing Address - Country:US
Mailing Address - Phone:262-695-1212
Mailing Address - Fax:262-695-1919
Practice Address - Street 1:1177 QUAIL CT
Practice Address - Street 2:SUITE 101
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3790
Practice Address - Country:US
Practice Address - Phone:262-695-1212
Practice Address - Fax:262-695-1919
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI381852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32265500Medicaid
WI32265500Medicaid
01150Medicare ID - Type Unspecified