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NPI Code Detail

MEDICARE: GRAND LAKE MENTAL HEALTH CENTER, INC.

MEDICARE: GRAND LAKE MENTAL HEALTH CENTER, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1324500000XSubstance Abuse Rehabilitation Facility640ADOK
2251S00000XCommunity/Behavioral Health Agency

General Provider Information

NPI Number : 1053317883
Entity Type Code : Organization
Provider Name (Legal Business Name) : GRAND LAKE MENTAL HEALTH CENTER, INC.
Provider Business Mailing Address
First Line : 114 W DELAWARE AVE
Second Line :
City : NOWATA
State : OK
Zip : 74048-2601
Country : US
Telephone Number : 918-273-1841
Fax Number : 918-273-1843
Provider Business Practice Location Address
First Line : 6333 E SKELLY DR
Second Line :
City : TULSA
State : OK
Zip : 74135-6106
Country : US
Telephone Number : 918-664-4224
Fax Number : 918-663-0203
Authorized Official
Title or Position : CEO
Name : JOSHUA CANTWELL
Credential :
Telephone Number : 918-273-1841
Provider Enumeration Date : 06/27/2005
Last Update Date : 10/17/2025

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Practice Fax: 918-663-0203

Directions to “GRAND LAKE MENTAL HEALTH CENTER, INC. ” Practice Location

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