Provider Demographics
NPI:1427850148
Name:LOUGH, KRISTINE
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:LOUGH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 N CENTRAL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3520
Mailing Address - Country:US
Mailing Address - Phone:602-283-1573
Mailing Address - Fax:
Practice Address - Street 1:1942 S AVENIDA URSA
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-5418
Practice Address - Country:US
Practice Address - Phone:520-907-6327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH10631385H00000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No385H00000XRespite Care FacilityRespite Care