Provider Demographics
NPI:1164968657
Name:GRANGER, CAMILLA B (BA, CAC III, NCAC II)
Entity Type:Individual
Prefix:
First Name:CAMILLA
Middle Name:B
Last Name:GRANGER
Suffix:
Gender:F
Credentials:BA, CAC III, NCAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 KLINE ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-1425
Mailing Address - Country:US
Mailing Address - Phone:303-669-8427
Mailing Address - Fax:303-997-1948
Practice Address - Street 1:4485 WADSWORTH. BLVD
Practice Address - Street 2:206
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-3310
Practice Address - Country:US
Practice Address - Phone:303-431-5664
Practice Address - Fax:303-431-6713
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2085101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03685039Medicaid