Provider Demographics
NPI:1407068430
Name:LOESCHER, MARY S (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:S
Last Name:LOESCHER
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 1:11904 CALLE ZAGAL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-4061
Mailing Address - Country:US
Mailing Address - Phone:505-553-6856
Mailing Address - Fax:
Practice Address - Street 1:1000 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5509
Practice Address - Country:US
Practice Address - Phone:505-721-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM396103T00000X
NM112126103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000N0153Medicaid