Provider Demographics
NPI:1366596678
Name:SHUB, LOIS LA (LP)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:LA
Last Name:SHUB
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 20TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-2217
Mailing Address - Country:US
Mailing Address - Phone:507-288-0395
Mailing Address - Fax:507-289-3731
Practice Address - Street 1:1425 20TH ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-2217
Practice Address - Country:US
Practice Address - Phone:507-288-0395
Practice Address - Fax:507-289-3731
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3932103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling