Healthcare Provider Details

I. General information

NPI: 1205466372
Provider Name (Legal Business Name): GRAND LAKE MENTAL HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3186 W HWY 412
WEST SILOAM SPRINGS OK
74338-1356
US

IV. Provider business mailing address

114 W DELAWARE AVE
NOWATA OK
74048-2601
US

V. Phone/Fax

Practice location:
  • Phone: 918-708-3006
  • Fax: 918-205-2712
Mailing address:
  • Phone: 918-273-1841
  • Fax: 918-273-1843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

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