Healthcare Provider Details

I. General information

NPI: 1437895224
Provider Name (Legal Business Name): GRACIE R BUENO LPC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3005 47TH ST STE F1
BOULDER CO
80301-5550
US

IV. Provider business mailing address

1942 BROADWAY STE 314C
BOULDER CO
80302-5233
US

V. Phone/Fax

Practice location:
  • Phone: 303-955-6830
  • Fax: 303-418-7733
Mailing address:
  • Phone: 303-994-0266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0018168
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: