Provider Demographics
NPI:1174260434
Name:GRAVEL ROAD MENTAL HEALTH SERVICES, PLLC
Entity Type:Organization
Organization Name:GRAVEL ROAD MENTAL HEALTH SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CARI
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:405-394-5298
Mailing Address - Street 1:PO BOX 904
Mailing Address - Street 2:
Mailing Address - City:MAUD
Mailing Address - State:OK
Mailing Address - Zip Code:74854-0904
Mailing Address - Country:US
Mailing Address - Phone:405-394-5298
Mailing Address - Fax:
Practice Address - Street 1:9905 S PENNSYLVANIA AVE STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6920
Practice Address - Country:US
Practice Address - Phone:405-394-5298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health