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General NPI Number Information
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NPI Number | 1215034830
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Entity Type | Individual
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Provider Name | ROGER A. LAIRD EDD
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Gender | Male
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Dates
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Enumeration Date | 09/17/2006
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Last Update Date | 07/11/2019
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Provider Practice Location Address
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Address Line | 200 CLINIC DR
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City | MADISONVILLE
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State | KY
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Zip | 42431-1661
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Country | US
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Telephone | 270-825-6680
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Fax | 270-825-7266
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Provider Business Mailing Address
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Address Line | 2700 STANLEY GAULT PKWY STE 129
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City | LOUISVILLE
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State | KY
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Zip | 40223-5176
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Country | US
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Telephone | 502-253-4900
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Fax | 502-489-5751
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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 | 0487
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License Number State | KY
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