Provider Demographics
NPI:1720213721
Name:ED D LAURITSEN PHD PC
Entity Type:Organization
Organization Name:ED D LAURITSEN PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAURITSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:928-367-9995
Mailing Address - Street 1:218 W WHITE MOUNTAIN BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929
Mailing Address - Country:US
Mailing Address - Phone:928-367-9995
Mailing Address - Fax:928-367-9988
Practice Address - Street 1:218 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929
Practice Address - Country:US
Practice Address - Phone:928-367-9995
Practice Address - Fax:928-367-9988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1256103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty