Provider Demographics
NPI:1629668272
Name:GARCILAZO, GRISELDA (LPCC)
Entity Type:Individual
Prefix:
First Name:GRISELDA
Middle Name:
Last Name:GARCILAZO
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-0155
Mailing Address - Country:US
Mailing Address - Phone:951-529-8886
Mailing Address - Fax:
Practice Address - Street 1:29567 GOLD BUCKLE RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-5821
Practice Address - Country:US
Practice Address - Phone:951-529-8886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC7373101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health