Healthcare Provider Details

I. General information

NPI: 1942012349
Provider Name (Legal Business Name): LEADING EDGE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 GOLD AVE SW # 256
ALBUQUERQUE NM
87102-3335
US

IV. Provider business mailing address

PO BOX 45681
RIO RANCHO NM
87174-5681
US

V. Phone/Fax

Practice location:
  • Phone: 417-501-9423
  • Fax: 505-672-7769
Mailing address:
  • Phone: 505-226-1960
  • Fax: 505-672-7769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JAMIE MARIE LOOR
Title or Position: OWNER
Credential: PHD
Phone: 417-501-9423