Healthcare Provider Details

I. General information

NPI: 1144064221
Provider Name (Legal Business Name): GRAY MATTERS PEDIATRIC BEHAVIORAL HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SOUTHTOWN CIR
ROLESVILLE NC
27571-9573
US

IV. Provider business mailing address

300 SOUTHTOWN CIR
ROLESVILLE NC
27571-9573
US

V. Phone/Fax

Practice location:
  • Phone: 919-435-4784
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER BALL
Title or Position: CEO/OWNER
Credential:
Phone: 919-435-4784