Healthcare Provider Details

I. General information

NPI: 1760563001
Provider Name (Legal Business Name): MR. BEN GRAYWOLF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 1ST ST NW
ALBUQUERQUE NM
87102-1529
US

IV. Provider business mailing address

1111 CARDENAS DR SE APT # 316
ALBUQUERQUE NM
87108-4736
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-6738
  • Fax: 505-344-1862
Mailing address:
  • Phone: 505-338-8027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberOO79341
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: