Healthcare Provider Details

I. General information

NPI: 1235329699
Provider Name (Legal Business Name): ANJA LEE GRISSOM MED & LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. ANJA LEE HEIDGERKEN

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 02/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 W 3RD ST
KONAWA OK
74849-1415
US

IV. Provider business mailing address

527 W 3RD ST
KONAWA OK
74849-1415
US

V. Phone/Fax

Practice location:
  • Phone: 580-925-3286
  • Fax: 580-925-2362
Mailing address:
  • Phone: 580-925-3286
  • Fax: 580-925-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2478
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: