Basic Information
| Provider Information | |||||||||
| NPI: | 1174640700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAGRAND | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1247 | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744651247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189319600 | ||||||||
| FaxNumber: | 9184568773 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 W CHICKASAW ST | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744644301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189319600 | ||||||||
| FaxNumber: | 9184568773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 727 | OK | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 04-1P | AR | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 533 | AK | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.