Provider Demographics
NPI:1760563001
Name:GRAYWOLF, BEN
Entity Type:Individual
Prefix:MR
First Name:BEN
Middle Name:
Last Name:GRAYWOLF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 CARDENAS DR SE
Mailing Address - Street 2:APT # 316
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4736
Mailing Address - Country:US
Mailing Address - Phone:505-338-8027
Mailing Address - Fax:
Practice Address - Street 1:1217 1ST ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1529
Practice Address - Country:US
Practice Address - Phone:505-344-6738
Practice Address - Fax:505-344-1862
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOO79341101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)