Provider Demographics
NPI:1093764771
Name:GEORGIC, KATHERINE A (BS)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:GEORGIC
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:KATHIE
Other - Middle Name:A
Other - Last Name:EZZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81602-0040
Mailing Address - Country:US
Mailing Address - Phone:970-945-2241
Mailing Address - Fax:970-945-5523
Practice Address - Street 1:1023 CTY RD 610
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CO
Practice Address - Zip Code:80446
Practice Address - Country:US
Practice Address - Phone:970-887-2179
Practice Address - Fax:970-887-9311
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6187101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)