Provider Demographics
NPI:1225262876
Name:LOERA, SHARON ANTONIA (LSAA)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:ANTONIA
Last Name:LOERA
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 LUTHY DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2849
Mailing Address - Country:US
Mailing Address - Phone:505-804-8094
Mailing Address - Fax:
Practice Address - Street 1:15 FEEDLOT LN
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-4790
Practice Address - Country:US
Practice Address - Phone:505-435-3630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0257101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM$$$$$$$$$Medicaid