Provider Demographics
NPI:1083987291
Name:GRAY MATTER PARTNERS
Entity Type:Organization
Organization Name:GRAY MATTER PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:ORTH
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED PSYCHOLOGIS
Authorized Official - Phone:612-716-3925
Mailing Address - Street 1:16809 260TH AVE
Mailing Address - Street 2:
Mailing Address - City:MC GRATH
Mailing Address - State:MN
Mailing Address - Zip Code:56350-4538
Mailing Address - Country:US
Mailing Address - Phone:612-716-3925
Mailing Address - Fax:
Practice Address - Street 1:16809 260TH AVE
Practice Address - Street 2:
Practice Address - City:MC GRATH
Practice Address - State:MN
Practice Address - Zip Code:56350-4538
Practice Address - Country:US
Practice Address - Phone:612-716-3925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-18
Last Update Date:2012-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4963261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health