Provider Demographics
NPI:1629031166
Name:LAIDLAW, ROBERT A (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:LAIDLAW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 30TH S AVE 101
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6009
Mailing Address - Country:US
Mailing Address - Phone:701-780-9700
Mailing Address - Fax:701-780-9709
Practice Address - Street 1:3301 30TH AVE S STE 101
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6009
Practice Address - Country:US
Practice Address - Phone:701-780-9700
Practice Address - Fax:701-780-9709
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND012274Medicaid
NDN711209Medicare ID - Type Unspecified