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
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1205466372
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	:	3186 W HWY 412
Second Line	:
City	:	WEST SILOAM SPRINGS
State	:	OK
Zip	:	74338-1356
Country	:	US
Telephone Number	:	918-708-3006
Fax Number	:	918-205-2712

Authorized Official
Title or Position	:	CEO
Name	:	LARRY SMITH
Credential	:
Telephone Number	:	918-273-1841

Provider Enumeration Date	:	01/17/2020
Last Update Date	:	06/13/2022

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