Provider Demographics
NPI:1942012349
Name:LEADING EDGE THERAPY LLC
Entity type:Organization
Organization Name:LEADING EDGE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOOR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:417-501-9423
Mailing Address - Street 1:PO BOX 45681
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-5681
Mailing Address - Country:US
Mailing Address - Phone:505-226-1960
Mailing Address - Fax:505-672-7769
Practice Address - Street 1:102 GOLD AVE SW # 256
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3335
Practice Address - Country:US
Practice Address - Phone:417-501-9423
Practice Address - Fax:505-672-7769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty