=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427640721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREY MATTER DIAGNOSTICS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2021
-----------------------------------------------------
Last Update Date | 02/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6712 KEITHWOOD CIR S
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-7150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-219-2114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5205 BROADWAY ST # 134
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77581-3942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | ASHLEY TOTTRESS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-509-5768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZE0500X
-----------------------------------------------------
Taxonomy Name | EEG Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------