Healthcare Provider Details

I. General information

NPI: 1417639600
Provider Name (Legal Business Name): LYNLY D. GRIDER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N MUSTANG RD STE E
MUSTANG OK
73064-7044
US

IV. Provider business mailing address

314 N JASPER WAY
MUSTANG OK
73064-2053
US

V. Phone/Fax

Practice location:
  • Phone: 405-256-8141
  • Fax:
Mailing address:
  • Phone: 405-990-5590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12264
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: