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General NPI Number Information
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NPI Number | 1134496896
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Entity Type | Individual
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Provider Name | ROBERT WILBUT LAURIDSEN PH.D.
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Gender | Male
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Dates
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Enumeration Date | 11/23/2011
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Last Update Date | 11/23/2011
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Provider Practice Location Address
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Address Line | 455 LOS GATOS BLVD #202
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City | LOS GATOS
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State | CA
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Zip | 95032-5523
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Country | US
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Telephone | 408-356-2141
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Fax |
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Provider Business Mailing Address
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Address Line | 19450 REDBERRY DR
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City | LOS GATOS
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State | CA
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Zip | 95030-2928
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Country | US
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Telephone | 408-398-4006
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Fax | 408-356-2143
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY 5763
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License Number State | CA
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