Basic Information
| Provider Information | |||||||||
| NPI: | 1437895224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUENO | ||||||||
| FirstName: | GRACIE | ||||||||
| MiddleName: | RODRIGUEZ | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 270 BERYL WAY | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800202316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039940266 | ||||||||
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| Practice Location | |||||||||
| Address1: | 305 CARPENTER RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706633500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2022 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0018168 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.