Healthcare Provider Details

I. General information

NPI: 1861625071
Provider Name (Legal Business Name): ANGELA MARY LOECKE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2009
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 10TH ST NE STE 3
AUSTIN MN
55912-3724
US

IV. Provider business mailing address

PO BOX 366
AUSTIN MN
55912-0366
US

V. Phone/Fax

Practice location:
  • Phone: 507-433-9120
  • Fax: 507-457-3027
Mailing address:
  • Phone: 507-433-9120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5152
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: