Provider Demographics
NPI:1720894710
Name:GRAY MATTERS THERAPY LLC
Entity type:Organization
Organization Name:GRAY MATTERS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNENWERTH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:507-450-7091
Mailing Address - Street 1:100 LATSCH SQ STE 203
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-2995
Mailing Address - Country:US
Mailing Address - Phone:515-710-4002
Mailing Address - Fax:
Practice Address - Street 1:100 LATSCH SQ STE 203
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-2995
Practice Address - Country:US
Practice Address - Phone:515-710-4002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-05
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty