Healthcare Provider Details

I. General information

NPI: 1164968657
Provider Name (Legal Business Name): CAMILLA B GRANGER BA, CAC III, NCAC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4485 WADSWORTH. BLVD 206
WHEAT RIDGE CO
80033-3310
US

IV. Provider business mailing address

2435 KLINE ST
LAKEWOOD CO
80215-1425
US

V. Phone/Fax

Practice location:
  • Phone: 303-431-5664
  • Fax: 303-431-6713
Mailing address:
  • Phone: 303-669-8427
  • Fax: 303-997-1948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2085
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: