Basic Information
| Provider Information | |||||||||
| NPI: | 1306874532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAI | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 W CALIFORNIA BLVD | ||||||||
| Address2: | # 297 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269634467 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 W CALIFORNIA BLVD | ||||||||
| Address2: | # 297 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269634467 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A66298 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00A662980 | 05 | CA | MEDICAID |