Healthcare Provider Details

I. General information

NPI: 1366802860
Provider Name (Legal Business Name): GRAND LAKE MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 E SKELLY DR
TULSA OK
74135-6106
US

IV. Provider business mailing address

6333 E SKELLY DR
TULSA OK
74135-6106
US

V. Phone/Fax

Practice location:
  • Phone: 918-664-4224
  • Fax: 918-664-8732
Mailing address:
  • Phone: 918-664-4224
  • Fax: 918-664-8732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateOK

VIII. Authorized Official

Name: LARRY SMITH
Title or Position: CEO
Credential:
Phone: 918-273-1841