Healthcare Provider Details

I. General information

NPI: 1164718177
Provider Name (Legal Business Name): CHRISTINE DEOGRACIAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S SHIELDS ST BLDG I
FORT COLLINS CO
80526-1827
US

IV. Provider business mailing address

301 SKYWAY DR
FORT COLLINS CO
80525-3911
US

V. Phone/Fax

Practice location:
  • Phone: 970-221-5255
  • Fax: 970-221-5206
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1690
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: