Healthcare Provider Details

I. General information

NPI: 1477963981
Provider Name (Legal Business Name): MARY JANE GREENLEY CACII
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2014
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S LINCOLN AVE
STEAMBOAT SPRINGS CO
80487
US

IV. Provider business mailing address

715 HORIZON DR STE 225
GRAND JUNCTION CO
81506-8700
US

V. Phone/Fax

Practice location:
  • Phone: 970-879-2141
  • Fax: 970-879-7912
Mailing address:
  • Phone: 970-683-7107
  • Fax: 970-683-7167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number7408
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: