Provider Demographics
NPI:1659504231
Name:LOZANO, MARYLOU H (COMMUNITY SUPPORT SP)
Entity Type:Individual
Prefix:MRS
First Name:MARYLOU
Middle Name:H
Last Name:LOZANO
Suffix:
Gender:F
Credentials:COMMUNITY SUPPORT SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2267
Mailing Address - Country:US
Mailing Address - Phone:505-954-2303
Mailing Address - Fax:
Practice Address - Street 1:901 WEST HICKORY ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030
Practice Address - Country:US
Practice Address - Phone:575-546-2174
Practice Address - Fax:575-544-4821
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid