Provider Demographics
NPI:1184174096
Name:LAIRD, ROGER GRANT (LMFT)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:GRANT
Last Name:LAIRD
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2543
Mailing Address - Country:US
Mailing Address - Phone:415-762-3700
Mailing Address - Fax:415-865-0119
Practice Address - Street 1:1563 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2543
Practice Address - Country:US
Practice Address - Phone:415-762-3700
Practice Address - Fax:415-865-0119
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115187106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXXXXXXMedicare UPIN