Healthcare Provider Details

I. General information

NPI: 1508388836
Provider Name (Legal Business Name): LAIRD PATRICK BRIDGMAN PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22792 CENTRE DR STE 103
LAKE FOREST CA
92630
US

IV. Provider business mailing address

22792 CENTRE DR STE 103
LAKE FOREST CA
92630
US

V. Phone/Fax

Practice location:
  • Phone: 949-636-2207
  • Fax: 949-770-5433
Mailing address:
  • Phone: 949-636-2207
  • Fax: 949-770-5433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY14510
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY14510
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY14510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: