Healthcare Provider Details

I. General information

NPI: 1487366746
Provider Name (Legal Business Name): GRAND LAKE MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 W WASHBOURNE ST
JAY OK
74346-4205
US

IV. Provider business mailing address

114 W DELAWARE AVE
NOWATA OK
74048-2601
US

V. Phone/Fax

Practice location:
  • Phone: 918-308-5513
  • Fax: 918-253-6645
Mailing address:
  • Phone: 918-273-1841
  • Fax: 918-273-1841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

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