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General NPI Number Information
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NPI Number | 1619050895
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Entity Type | Individual
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Provider Name | ELIZABETH MOLLETTE GRUNDY PH.D.
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Gender | Female
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1520 NORTH INDUSTRIAL ROAD
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City | VINITA
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State | OK
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Zip | 74301
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Country | US
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Telephone | 918-629-8664
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Fax | 918-782-4301
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Provider Business Mailing Address
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Address Line | PO BOX 426
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City | VINITA
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State | OK
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Zip | 74301-0426
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Country | US
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Telephone | 918-629-8664
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Fax | 918-782-4301
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number | 750
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License Number State | OK
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