Provider Demographics
NPI:1023557139
Name:GRISSOM, STEPHEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3736 E 82ND PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-1605
Mailing Address - Country:US
Mailing Address - Phone:918-899-1393
Mailing Address - Fax:
Practice Address - Street 1:3736 E 82ND PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-1605
Practice Address - Country:US
Practice Address - Phone:918-899-1393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK467103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist