Healthcare Provider Details

I. General information

NPI: 1467362756
Provider Name (Legal Business Name): GREY STREET COLLABORATIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 BEASLEY LN
CAMPBELLSBURG KY
40011-6700
US

IV. Provider business mailing address

1931 BEASLEY LN
CAMPBELLSBURG KY
40011-6700
US

V. Phone/Fax

Practice location:
  • Phone: 502-667-0321
  • Fax: 972-928-6614
Mailing address:
  • Phone: 502-667-0321
  • Fax: 972-928-6614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY MAUREEN BAKER
Title or Position: OWNER
Credential: APRN
Phone: 502-667-0321