Provider Demographics
NPI:1508330101
Name:GRAY HORSE MENTAL WELLNESS LLC
Entity Type:Organization
Organization Name:GRAY HORSE MENTAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:AYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:913-638-1246
Mailing Address - Street 1:4917 WOODSTOCK ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66218-9141
Mailing Address - Country:US
Mailing Address - Phone:913-638-1246
Mailing Address - Fax:
Practice Address - Street 1:3500 N 99TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66109
Practice Address - Country:US
Practice Address - Phone:913-638-1246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty