Provider Demographics
NPI:1700942810
Name:LOESER, MARK SEBASTIAN
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:SEBASTIAN
Last Name:LOESER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:SEBASTIAN
Other - Last Name:LOESER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:4635 S LAKESHORE DR
Mailing Address - Street 2:SUITE 116
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7127
Mailing Address - Country:US
Mailing Address - Phone:480-345-4531
Mailing Address - Fax:480-345-4563
Practice Address - Street 1:4635 S LAKESHORE DR
Practice Address - Street 2:SUITE 116
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7127
Practice Address - Country:US
Practice Address - Phone:480-345-4531
Practice Address - Fax:480-345-4563
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-1288101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional