Healthcare Provider Details

I. General information

NPI: 1104096486
Provider Name (Legal Business Name): GRACE VILLA OLAGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4791 S LINCOLN RIDGE DR
TUCSON AZ
85730-4815
US

IV. Provider business mailing address

6141 E GRANT RD BLDG A
TUCSON AZ
85712-5829
US

V. Phone/Fax

Practice location:
  • Phone: 520-900-2749
  • Fax:
Mailing address:
  • Phone: 602-708-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number639513
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number639516
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: