Basic Information
| Provider Information | |||||||||
| NPI: | 1013925882 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRAND LAKE MENTAL HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAND LAKE MENTAL HEALTH CENTER, INC.-AFTON CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 W DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | NOWATA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740482601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182574244 | ||||||||
| FaxNumber: | 9182574247 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 S. MAIN | ||||||||
| Address2: | |||||||||
| City: | AFTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182574244 | ||||||||
| FaxNumber: | 9182574247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MIS/REIMBURSEMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9182731841 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.