Provider Demographics
NPI:1699751750
Name:LOOS, MICHAEL DALE (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DALE
Last Name:LOOS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 BOSWELL DR
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-8101
Mailing Address - Country:US
Mailing Address - Phone:307-721-4309
Mailing Address - Fax:
Practice Address - Street 1:1724 BOSWELL DR
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-8101
Practice Address - Country:US
Practice Address - Phone:307-721-4309
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYNCC 48217101Y00000X
WYLAT 245101YA0400X
WYLPC 672101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional