Provider Demographics
NPI:1013604446
Name:LOOSLE, LISA (EDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LOOSLE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 W ANN TAYLOR ST APT M101
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4022
Mailing Address - Country:US
Mailing Address - Phone:208-494-4487
Mailing Address - Fax:
Practice Address - Street 1:529 NW PRIMA VISTA BLVD STE 301L
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8790
Practice Address - Country:US
Practice Address - Phone:772-404-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1768103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool