Provider Demographics
NPI:1164775250
Name:STATE OF GRACE
Entity Type:Organization
Organization Name:STATE OF GRACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MAES
Authorized Official - Suffix:JR
Authorized Official - Credentials:CAC III
Authorized Official - Phone:719-240-1799
Mailing Address - Street 1:720 N MAIN ST STE 330
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3047
Mailing Address - Country:US
Mailing Address - Phone:719-569-7909
Mailing Address - Fax:
Practice Address - Street 1:720 N MAIN ST STE 330
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3047
Practice Address - Country:US
Practice Address - Phone:719-569-7909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1727-01251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health