Provider Demographics
NPI:1659430577
Name:KNIPE LAIRD, HEIDI D (PHD)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:D
Last Name:KNIPE LAIRD
Suffix:
Gender:F
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:PO BOX 5922
Mailing Address - Street 2:1325 AUTO PLAZE DR SUITE 110
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408
Mailing Address - Country:US
Mailing Address - Phone:909-885-0411
Mailing Address - Fax:951-784-1841
Practice Address - Street 1:1325 AUTO PLAZA DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:909-885-0411
Practice Address - Fax:951-784-1841
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA PSY 10935103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33BE10OtherRIVERSIDE COUNTY DCS
CA9455029Medicaid