Provider Demographics
NPI:1205613965
Name:GREY SPACE LLC
Entity type:Organization
Organization Name:GREY SPACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:205-202-1883
Mailing Address - Street 1:429 GREEN SPRINGS HWY STE 161-367
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-4935
Mailing Address - Country:US
Mailing Address - Phone:205-202-1883
Mailing Address - Fax:
Practice Address - Street 1:6001 OLD LEEDS RD
Practice Address - Street 2:
Practice Address - City:IRONDALE
Practice Address - State:AL
Practice Address - Zip Code:35210-4292
Practice Address - Country:US
Practice Address - Phone:205-202-1883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty