Provider Demographics
NPI:1275171274
Name:GRAND LAKE MENTAL HEALTH
Entity Type:Organization
Organization Name:GRAND LAKE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RSS
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-791-5453
Mailing Address - Street 1:111 S TREATY RD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-5327
Mailing Address - Country:US
Mailing Address - Phone:918-418-3062
Mailing Address - Fax:
Practice Address - Street 1:111 S TREATY RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-5327
Practice Address - Country:US
Practice Address - Phone:918-418-3062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-20
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty