Provider Demographics
NPI:1023004686
Name:LAURITSEN, EDDIE DUANE
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:DUANE
Last Name:LAURITSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ED
Other - Middle Name:D
Other - Last Name:LAURITSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1141 E COOLEY ST
Mailing Address - Street 2:STE E
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-5103
Mailing Address - Country:US
Mailing Address - Phone:928-537-0370
Mailing Address - Fax:928-537-1189
Practice Address - Street 1:1141 E COOLEY ST
Practice Address - Street 2:STE E
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-5103
Practice Address - Country:US
Practice Address - Phone:928-537-0370
Practice Address - Fax:928-537-1189
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1256103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R03056Medicare UPIN
PHD1256Medicare ID - Type Unspecified