MEDICARE: MRS. LYNLY D. GRIDER LPC

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	171M00000X	Case Manager/Care Coordinator
2	101YM0800X	Mental Health Counselor	12264	OK

General Provider Information

NPI Number	:	1417639600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYNLY D. GRIDER LPC

Provider Business Mailing Address
First Line	:	314 N JASPER WAY
Second Line	:
City	:	MUSTANG
State	:	OK
Zip	:	73064-2053
Country	:	US
Telephone Number	:	405-990-5590
Fax Number	:

Provider Business Practice Location Address
First Line	:	3801 NW 63RD ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1921
Country	:	US
Telephone Number	:	918-268-7295
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2023
Last Update Date	:	05/08/2026

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