Provider Demographics
NPI:1962959585
Name:GARZA, GRACE BERLANGA
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:BERLANGA
Last Name:GARZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1417
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-1417
Mailing Address - Country:US
Mailing Address - Phone:719-336-2600
Mailing Address - Fax:719-336-3669
Practice Address - Street 1:1006 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-3814
Practice Address - Country:US
Practice Address - Phone:719-336-2600
Practice Address - Fax:719-336-3669
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACA0007267101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)