Healthcare Provider Details

I. General information

NPI: 1003292061
Provider Name (Legal Business Name): GRAND LAKE MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 SE WASHINGTON BLVD
BARTLESVILLE OK
74006-4519
US

IV. Provider business mailing address

1370 SE WASHINGTON BLVD
BARTLESVILLE OK
74006-4519
US

V. Phone/Fax

Practice location:
  • Phone: 918-337-8080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LARRY SMITH
Title or Position: CEO
Credential:
Phone: 918-273-1841