Provider Demographics
NPI:1164433157
Name:GRAYBILL, BEVAN TODD (PHD)
Entity Type:Individual
Prefix:DR
First Name:BEVAN
Middle Name:TODD
Last Name:GRAYBILL
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 1:333 S 38TH ST
Mailing Address - Street 2:SUITE K
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4937
Mailing Address - Country:US
Mailing Address - Phone:918-683-8827
Mailing Address - Fax:918-686-0902
Practice Address - Street 1:333 S 38TH ST
Practice Address - Street 2:SUITE K
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4937
Practice Address - Country:US
Practice Address - Phone:918-683-8827
Practice Address - Fax:918-686-0902
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK353103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical