Provider Demographics
NPI:1134496896
Name:LAURIDSEN, ROBERT WILBUT (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILBUT
Last Name:LAURIDSEN
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 1:19450 REDBERRY DR
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-2928
Mailing Address - Country:US
Mailing Address - Phone:408-398-4006
Mailing Address - Fax:408-356-2143
Practice Address - Street 1:455 LOS GATOS BLVD
Practice Address - Street 2:#202
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-5523
Practice Address - Country:US
Practice Address - Phone:408-356-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5763103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist