Provider Demographics
NPI:1265767024
Name:LAIDIG, JOAN MARLENE (PHD)
Entity type:Individual
Prefix:DR
First Name:JOAN
Middle Name:MARLENE
Last Name:LAIDIG
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 1:719 FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-6019
Mailing Address - Country:US
Mailing Address - Phone:626-403-3500
Mailing Address - Fax:626-403-6894
Practice Address - Street 1:719 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-6019
Practice Address - Country:US
Practice Address - Phone:626-403-3500
Practice Address - Fax:626-403-6894
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18935103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist