Healthcare Provider Details

I. General information

NPI: 1114258100
Provider Name (Legal Business Name): LANCE MALLOY GRACE B.S. M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 N LINCOLN BLVD
OKLAHOMA CITY OK
73105-5104
US

IV. Provider business mailing address

2416 NW 49TH ST
OKLAHOMA CITY OK
73112-8323
US

V. Phone/Fax

Practice location:
  • Phone: 405-525-0452
  • Fax:
Mailing address:
  • Phone: 405-306-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: