Healthcare Provider Details

I. General information

NPI: 1689538134
Provider Name (Legal Business Name): GRACIOUS GROWTH NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 RIVERSIDE PLAZA LN NW STE 118
ALBUQUERQUE NM
87120-2617
US

IV. Provider business mailing address

6300 RIVERSIDE PLAZA LN NW STE 118
ALBUQUERQUE NM
87120-2617
US

V. Phone/Fax

Practice location:
  • Phone: 917-771-4207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: AVROHOM MARMORSTEIN
Title or Position: CEO
Credential:
Phone: 844-408-3757