Provider Demographics
NPI:1356713457
Name:MONROE, CALLI GRACE (LAC)
Entity type:Individual
Prefix:
First Name:CALLI
Middle Name:GRACE
Last Name:MONROE
Suffix:
Gender:F
Credentials:LAC
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 1576
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86339-1576
Mailing Address - Country:US
Mailing Address - Phone:982-848-7633
Mailing Address - Fax:
Practice Address - Street 1:1835 W STATE ROUTE 89A STE 2
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-5570
Practice Address - Country:US
Practice Address - Phone:928-202-9187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
AZ17533101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling