Provider Demographics
NPI:1215034830
Name:LAIRD, ROGER A (EDD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:LAIRD
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:200 CLINIC DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1661
Practice Address - Country:US
Practice Address - Phone:270-825-6680
Practice Address - Fax:270-825-7266
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0487103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY89000202Medicaid
000000261031OtherBCBS PROVIDER NUMBER
KY000000787401OtherBCBS BAPTIST HEALTH
KY0487OtherLICENSE
0374562Medicare PIN
KY000000787401OtherBCBS BAPTIST HEALTH
KY89000202Medicaid
0375111Medicare PIN
0375067Medicare PIN
000000261031OtherBCBS PROVIDER NUMBER
KY0487OtherLICENSE
KYK060241Medicare PIN
KY620006343Medicare PIN