Provider Demographics
NPI:1518506302
Name:GRIJALVA, LAYLA
Entity Type:Individual
Prefix:
First Name:LAYLA
Middle Name:
Last Name:GRIJALVA
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 1:1011 HALL PL
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9135
Mailing Address - Country:US
Mailing Address - Phone:505-402-3464
Mailing Address - Fax:
Practice Address - Street 1:1011 HALL PL
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9135
Practice Address - Country:US
Practice Address - Phone:505-402-3464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician