Healthcare Provider Details

I. General information

NPI: 1639073182
Provider Name (Legal Business Name): GRAND LAKE MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 N GRAND ST
ENID OK
73701-3221
US

IV. Provider business mailing address

114 W DELAWARE AVE
NOWATA OK
74048-2601
US

V. Phone/Fax

Practice location:
  • Phone: 580-234-3791
  • Fax:
Mailing address:
  • Phone: 918-273-1841
  • Fax: 918-273-1843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOSHUA CANTWELL
Title or Position: CEO
Credential:
Phone: 918-273-1841