Provider Demographics
NPI:1174134647
Name:GRANT, RAEGAN ELIZABETH
Entity type:Individual
Prefix:
First Name:RAEGAN
Middle Name:ELIZABETH
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 S BOULDER CIR APT 6015
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4287
Mailing Address - Country:US
Mailing Address - Phone:720-213-8142
Mailing Address - Fax:
Practice Address - Street 1:1942 BROADWAY STE 314C
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5233
Practice Address - Country:US
Practice Address - Phone:720-213-8142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COLPCC.0019525101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program