Provider Demographics
NPI:1700696556
Name:LOEB, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:LOEB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 SIERRA DR
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-8319
Mailing Address - Country:US
Mailing Address - Phone:301-602-8745
Mailing Address - Fax:
Practice Address - Street 1:434 TURNER DR
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-8986
Practice Address - Country:US
Practice Address - Phone:301-602-8745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0009926027104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty