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General NPI Number Information
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NPI Number | 1942012349
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Entity Type | Organization
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Legal Business Name | LEADING EDGE THERAPY LLC
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Dates
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Enumeration Date | 01/22/2025
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 102 GOLD AVE SW # 256
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-3335
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Country | US
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Telephone | 417-501-9423
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Fax | 505-672-7769
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Provider Business Mailing Address
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Address Line | PO BOX 45681
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City | RIO RANCHO
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State | NM
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Zip | 87174-5681
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Country | US
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Telephone | 505-226-1960
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Fax | 505-672-7769
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Authorized Official
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Title or Position | OWNER
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Name | JAMIE MARIE LOOR
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Credential | PHD
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Telephone | 417-501-9423
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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