Basic Information
| Provider Information | |||||||||
| NPI: | 1487263786 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOUTON | ||||||||
| FirstName: | SHANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2441 CABEZON BLVD SE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871241576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057171155 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2441 CABEZON BLVD SE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871241576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057171155 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2020 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | M-11502 | NM | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | M-11502 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.