Provider Demographics
NPI:1255752002
Name:GRIEGO, RENAE
Entity type:Individual
Prefix:
First Name:RENAE
Middle Name:
Last Name:GRIEGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENAE
Other - Middle Name:NICOLE
Other - Last Name:GRIEGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:10823 JEWEL CAVE RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-5910
Mailing Address - Country:US
Mailing Address - Phone:505-239-6430
Mailing Address - Fax:
Practice Address - Street 1:119 LUNA AVE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-865-9636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1240224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant