MEDICARE: MARK GREBENER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LAC127	CO
2	1041C0700X	Clinical Social Worker	CSW434	CO
3	1041C0700X	Clinical Social Worker		IL

General Provider Information

NPI Number	:	1063697738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK GREBENER, LLC

Provider Business Mailing Address
First Line	:	1418 E IRWIN LN
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80122-3081
Country	:	US
Telephone Number	:	303-883-4808
Fax Number	:	303-794-6736

Provider Business Practice Location Address
First Line	:	7900 E UNION AVE
Second Line	:	SUITE 1100
City	:	DENVER
State	:	CO
Zip	:	80237-2735
Country	:	US
Telephone Number	:	303-883-4808
Fax Number	:	303-794-6736

Authorized Official
Title or Position	:	PRINCIPAL
Name	:	MARK GREBENER
Credential	:	LCSW, LAC
Telephone Number	:	303-883-4808

Provider Enumeration Date	:	12/31/2007
Last Update Date	:	12/31/2007

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