Healthcare Provider Details

I. General information

NPI: 1285404095
Provider Name (Legal Business Name): GREY MATTER BEHAVIORAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 12/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4524 PALMYRA AVE NW
ALBUQUERQUE NM
87114-4241
US

IV. Provider business mailing address

4524 PALMYRA AVE NW
ALBUQUERQUE NM
87114-4241
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-4632
  • Fax:
Mailing address:
  • Phone: 505-715-9584
  • Fax:

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: TOYIN OLADEJI
Title or Position: EXECUTIVE DIRECTOR
Credential: PMHNP
Phone: 505-433-4632