MEDICARE: MS. KATHLEEN GRACE MA LPC CACII

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	6066	CO
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	7405	CO

General Provider Information

NPI Number	:	1841275286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHLEEN GRACE MA LPC CACII

Provider Business Mailing Address
First Line	:	PO BOX 40
Second Line	:
City	:	GLENWOOD SPRINGS
State	:	CO
Zip	:	81602-0040
Country	:	US
Telephone Number	:	970-945-2241
Fax Number	:	970-945-5523

Provider Business Practice Location Address
First Line	:	515 28 3/4 RD
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81501-5016
Country	:	US
Telephone Number	:	970-241-6023
Fax Number	:	970-242-8330

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2005
Last Update Date	:	05/18/2011

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