Provider Demographics
NPI:1457174302
Name:GRACIOUS GROWTH COLORADO LLC
Entity type:Organization
Organization Name:GRACIOUS GROWTH COLORADO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AVI
Authorized Official - Middle Name:
Authorized Official - Last Name:MARMORSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-771-4207
Mailing Address - Street 1:4845 PEARL EAST CIR STE 118
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-6112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4845 PEARL EAST CIR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-6110
Practice Address - Country:US
Practice Address - Phone:917-771-4207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty