Healthcare Provider Details

I. General information

NPI: 1386163574
Provider Name (Legal Business Name): LORI JO KOMETER MA, LIAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8727 E KEATS AV
MESA AZ
85209-5351
US

IV. Provider business mailing address

8727 E KEATS AV
MESA AZ
85209-5351
US

V. Phone/Fax

Practice location:
  • Phone: 480-329-7486
  • Fax: 602-425-7045
Mailing address:
  • Phone: 480-329-7486
  • Fax: 602-425-7045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLASAC-13266
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLIAC-15081
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: