Healthcare Provider Details

I. General information

NPI: 1306854245
Provider Name (Legal Business Name): GRAND LAKE MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S TREATY RD
MIAMI OK
74354-5326
US

IV. Provider business mailing address

114 W DELAWARE AVE
NOWATA OK
74048-2601
US

V. Phone/Fax

Practice location:
  • Phone: 918-540-1511
  • Fax: 918-542-7374
Mailing address:
  • Phone: 918-540-1511
  • Fax: 918-542-7374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: REBECCA COX
Title or Position: MIS/REIMBURSEMENT COORDINATOR
Credential:
Phone: 918-273-1841