Healthcare Provider Details

I. General information

NPI: 1700233699
Provider Name (Legal Business Name): GRAY WOLF COUNSELING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

854 MISSION VALLEY RD
CORRALES NM
87048-7829
US

IV. Provider business mailing address

854 MISSION VALLEY RD
CORRALES NM
87048-7829
US

V. Phone/Fax

Practice location:
  • Phone: 505-506-1877
  • Fax:
Mailing address:
  • Phone: 505-506-1877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0125
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0162551
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0145071
License Number StateNM

VIII. Authorized Official

Name: MR. ROBERT HOWARD MEDDAUGH
Title or Position: OWNER - THERAPIST
Credential: MS,MFT,LADC, CPGC
Phone: 505-506-1877