Provider Demographics
NPI:1760762876
Name:LOOPER, CARLY (LAC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:LOOPER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9324 E RAINTREE DR
Mailing Address - Street 2:100B
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-7316
Mailing Address - Country:US
Mailing Address - Phone:303-349-7786
Mailing Address - Fax:
Practice Address - Street 1:9324 E RAINTREE DR
Practice Address - Street 2:100B
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-7316
Practice Address - Country:US
Practice Address - Phone:303-349-7786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC13432101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health