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General NPI Number Information
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NPI Number | 1356048656
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Entity Type | Organization
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Legal Business Name | GRAND LAKE MENTAL HEALTH CENTER, INC.
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Dates
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Enumeration Date | 02/08/2023
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Last Update Date | 11/25/2025
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Provider Practice Location Address
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Address Line | 6111 E SKELLY DR
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City | TULSA
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State | OK
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Zip | 74135-6100
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Country | US
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Telephone | 918-664-4224
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Fax | 918-663-0303
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Provider Business Mailing Address
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Address Line | 6111 E SKELLY DR
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City | TULSA
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State | OK
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Zip | 74135-6100
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Country | US
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Telephone | 918-664-4224
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Fax | 918-663-0303
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Authorized Official
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Title or Position | CEO
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Name | JOSHUA CANTWELL
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Credential |
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Telephone | 918-273-1841
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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