Basic Information
| Provider Information | |||||||||
| NPI: | 1902358120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BJUSTROM | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | DONNELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1144 FORSETH DR | ||||||||
| Address2: | |||||||||
| City: | HARTLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530292279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143335816 | ||||||||
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| Practice Location | |||||||||
| Address1: | 741 N GRAND AVE STE 302 | ||||||||
| Address2: | |||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531864841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2927891191 | ||||||||
| FaxNumber: | 2625420823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3417-57 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 100062371 | 05 | WI | MEDICAID |