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General NPI Number Information
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NPI Number | 1861895625
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Entity Type | Organization
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Legal Business Name | DR.G, PSYD, PLLC
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Dates
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Enumeration Date | 10/07/2014
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Last Update Date | 10/07/2014
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Provider Practice Location Address
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Address Line | 1985 W 33RD ST
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City | EDMOND
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State | OK
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Zip | 73013-3875
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Country | US
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Telephone | 405-309-9051
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Fax |
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Provider Business Mailing Address
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Address Line | 1985 W 33RD ST
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City | EDMOND
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State | OK
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Zip | 73013-3875
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GRICELDA FRAGOSO
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Credential | PSYD
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Telephone | 405-309-9051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1131
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License Number State | OK
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