Basic Information
| Provider Information | |||||||||
| NPI: | 1710512462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOUCKS | ||||||||
| FirstName: | ISAI | ||||||||
| MiddleName: | VALDEZ | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 N 33RD AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850175202 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 N 33RD AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850175202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023530703 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2020 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 0 | AZ | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | 247451 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.