Healthcare Provider Details

I. General information

NPI: 1457729105
Provider Name (Legal Business Name): PERLA RAMIREZ-GROOTHUIS MS, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W 13TH ST
PUEBLO CO
81003-3754
US

IV. Provider business mailing address

212 W 13TH ST
PUEBLO CO
81003-3754
US

V. Phone/Fax

Practice location:
  • Phone: 719-696-9027
  • Fax:
Mailing address:
  • Phone: 719-696-9027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberNLC
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: