Healthcare Provider Details

I. General information

NPI: 1447388178
Provider Name (Legal Business Name): ALLIE GRANTHAM MHR, LPC, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 N OAK AVE
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

31824 E 720 RD
WAGONER OK
74467-7374
US

V. Phone/Fax

Practice location:
  • Phone: 918-444-2126
  • Fax: 918-458-2300
Mailing address:
  • Phone: 918-485-9661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6374
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: