Provider Demographics
NPI:1679932867
Name:GRIJALVA, EDWARD SR
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:GRIJALVA
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 N CAMPBELL AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-3164
Mailing Address - Country:US
Mailing Address - Phone:520-623-6015
Mailing Address - Fax:520-623-4590
Practice Address - Street 1:2601 N CAMPBELL AVE STE 108
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-3164
Practice Address - Country:US
Practice Address - Phone:520-623-6015
Practice Address - Fax:520-623-4590
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11811101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)