Provider Demographics
NPI:1700233699
Name:GRAY WOLF COUNSELING, INC.
Entity Type:Organization
Organization Name:GRAY WOLF COUNSELING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:MEDDAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MS,MFT,LADC, CPGC
Authorized Official - Phone:505-506-1877
Mailing Address - Street 1:854 MISSION VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-7829
Mailing Address - Country:US
Mailing Address - Phone:505-506-1877
Mailing Address - Fax:
Practice Address - Street 1:854 MISSION VALLEY RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-7829
Practice Address - Country:US
Practice Address - Phone:505-506-1877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0125101Y00000X
NM0162551101YA0400X
NM0145071106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM033514011OtherNM CRS