Basic Information
| Provider Information | |||||||||
| NPI: | 1093764771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGIC | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EZZO | ||||||||
| OtherFirstName: | KATHIE | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816020040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709452241 | ||||||||
| FaxNumber: | 9709455523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1023 CTY RD 610 | ||||||||
| Address2: | |||||||||
| City: | GRANBY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708872179 | ||||||||
| FaxNumber: | 9708879311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 01/18/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6187 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.