Basic Information
| Provider Information | |||||||||
| NPI: | 1043842370 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRAND LAKE MENTAL HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAND MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 W DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | NOWATA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740482601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182731841 | ||||||||
| FaxNumber: | 9182731843 | ||||||||
| Practice Location | |||||||||
| Address1: | 407 W SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | PONCA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746016133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803085515 | ||||||||
| FaxNumber: | 5807495792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2020 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9182731841 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.