Provider Demographics
NPI:1558521922
Name:O'LOUGHLIN, LISA JANE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JANE
Last Name:O'LOUGHLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 CERRILLOS RD
Mailing Address - Street 2:PO BOX6094
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3373
Mailing Address - Country:US
Mailing Address - Phone:505-438-0010
Mailing Address - Fax:505-438-6011
Practice Address - Street 1:2325 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3373
Practice Address - Country:US
Practice Address - Phone:505-438-0010
Practice Address - Fax:505-438-6011
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0176531101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health