Healthcare Provider Details

I. General information

NPI: 1346162922
Provider Name (Legal Business Name): BALVINA EVELYN LOERA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3724 N 3RD ST FL 2
PHOENIX AZ
85012-2034
US

IV. Provider business mailing address

3030 N CENTRAL AVE STE 506
PHOENIX AZ
85012-2825
US

V. Phone/Fax

Practice location:
  • Phone: 602-626-8112
  • Fax: 602-875-0242
Mailing address:
  • Phone: 602-626-8112
  • Fax: 480-409-3479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLAC-24157
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: