Healthcare Provider Details

I. General information

NPI: 1730539107
Provider Name (Legal Business Name): BECKIE M GRGICH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 KELLY JOHNSON BLVD SUITE 212
COLORADO SPRINGS CO
80920-3955
US

IV. Provider business mailing address

PO BOX 3392
MONUMENT CO
80132-3392
US

V. Phone/Fax

Practice location:
  • Phone: 719-344-8779
  • Fax: 719-313-9210
Mailing address:
  • Phone: 719-344-8779
  • Fax: 719-333-9210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0003041
License Number StateCO

VIII. Authorized Official

Name: BECKIE GRGICH
Title or Position: OWNER
Credential: PST.D.
Phone: 719-344-8779