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General NPI Number Information
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NPI Number | 1639537970
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Entity Type | Organization
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Legal Business Name | GRACE THERAPY, INC.
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Dates
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Enumeration Date | 02/01/2016
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Last Update Date | 02/01/2016
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Provider Practice Location Address
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Address Line | 4870 S LEWIS AVE SUITE 190
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City | TULSA
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State | OK
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Zip | 74105-5151
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Country | US
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Telephone | 918-869-5544
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Fax |
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Provider Business Mailing Address
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Address Line | 4870 S LEWIS AVE SUITE 190
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City | TULSA
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State | OK
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Zip | 74105-5151
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Country | US
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Telephone | 918-869-5544
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH PROFESSIONAL
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Name | MYLINDA RENEE FANJ
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Credential | MS, LPC
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Telephone | 918-869-5544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 4921
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License Number State | OK
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