Provider Demographics
NPI:1619308350
Name:CARBAJAL, GREG (MSW)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:CARBAJAL
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E. 13TH STREET
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001
Mailing Address - Country:US
Mailing Address - Phone:719-546-6666
Mailing Address - Fax:
Practice Address - Street 1:1625 GAYLORD AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2660
Practice Address - Country:US
Practice Address - Phone:719-821-7274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility