=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205613965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREY SPACE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2023
-----------------------------------------------------
Last Update Date | 09/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6001 OLD LEEDS RD
-----------------------------------------------------
City | IRONDALE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35210-4292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-202-1883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 429 GREEN SPRINGS HWY STE 161-367
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35209-4935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-202-1883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SARAH ELISE TIDWELL
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 205-202-1883
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------