Provider Demographics
NPI:1811210958
Name:LAIRD, GEORGE SAMUEL JR (PHD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:SAMUEL
Last Name:LAIRD
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:BUD
Other - Middle Name:
Other - Last Name:LAIRD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:37068 MUDGE RANCH RD
Mailing Address - Street 2:
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614-9704
Mailing Address - Country:US
Mailing Address - Phone:559-683-2166
Mailing Address - Fax:
Practice Address - Street 1:37068 MUDGE RANCH RD
Practice Address - Street 2:
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614-9704
Practice Address - Country:US
Practice Address - Phone:559-683-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 6457103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist