Provider Demographics
NPI:1700158961
Name:FRAIJO, GREGORIA MERCEDES
Entity Type:Individual
Prefix:
First Name:GREGORIA
Middle Name:MERCEDES
Last Name:FRAIJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:994 S HARRISON RD
Mailing Address - Street 2:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:
Practice Address - Street 1:8901 E 25TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710
Practice Address - Country:US
Practice Address - Phone:520-312-5172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
AZ2899097171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1700158961OtherTHERAPEUTIC FOSTER CARE