Healthcare Provider Details

I. General information

NPI: 1578024832
Provider Name (Legal Business Name): ELIZABETH LOOSLI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 CURLEW DR
AMMON ID
83406-4718
US

IV. Provider business mailing address

PO BOX 2106
IDAHO FALLS ID
83403-2106
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-5319
  • Fax: 208-523-5627
Mailing address:
  • Phone: 208-523-5319
  • Fax: 208-523-5627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-41598
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLMSW-37842
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: