Provider Demographics
NPI:1720857378
Name:GREY MATTER BEHAVIORAL WELLNESS LLC
Entity Type:Organization
Organization Name:GREY MATTER BEHAVIORAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TOYIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLADEJI
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:505-433-4632
Mailing Address - Street 1:4524 PALMYRA AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4241
Mailing Address - Country:US
Mailing Address - Phone:505-433-4632
Mailing Address - Fax:505-792-3221
Practice Address - Street 1:7916 BRADY RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1246
Practice Address - Country:US
Practice Address - Phone:505-433-4632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-25
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty