Provider Demographics
NPI:1558068411
Name:LOOMER, ALLY
Entity Type:Individual
Prefix:
First Name:ALLY
Middle Name:
Last Name:LOOMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:PAIGE
Other - Last Name:LOOMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:961 FLANNERY ST APT M
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-5257
Mailing Address - Country:US
Mailing Address - Phone:951-463-8462
Mailing Address - Fax:
Practice Address - Street 1:961 FLANNERY ST APT M
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-5257
Practice Address - Country:US
Practice Address - Phone:951-463-8462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician