Provider Demographics
NPI:1922157270
Name:LOOSLE, JOHN W (MSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:LOOSLE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 822
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040
Mailing Address - Country:US
Mailing Address - Phone:928-645-2744
Mailing Address - Fax:928-645-2745
Practice Address - Street 1:819 NO. NAVAJO DR.
Practice Address - Street 2:SUITE # 4
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040
Practice Address - Country:US
Practice Address - Phone:928-645-2744
Practice Address - Fax:928-645-2745
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11712101YA0400X
AZLCSE-28191041C0700X
UT113433-35011041C0700X
UT113433-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ797095Medicaid
AZZ83296Medicare ID - Type UnspecifiedPROVIDER NUMBER