Healthcare Provider Details

I. General information

NPI: 1366596678
Provider Name (Legal Business Name): LOIS L.A. SHUB L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 20TH ST SW
ROCHESTER MN
55902-2217
US

IV. Provider business mailing address

1425 20TH ST SW
ROCHESTER MN
55902-2217
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-0395
  • Fax: 507-289-3731
Mailing address:
  • Phone: 507-288-0395
  • Fax: 507-289-3731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP3932
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: