Provider Demographics
NPI:1447388178
Name:GRANTHAM, ALLIE (MHR, LPC, CADC)
Entity Type:Individual
Prefix:MRS
First Name:ALLIE
Middle Name:
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:MHR, LPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31824 E 720 RD
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-7374
Mailing Address - Country:US
Mailing Address - Phone:918-485-9661
Mailing Address - Fax:
Practice Address - Street 1:529 N OAK AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-444-2126
Practice Address - Fax:918-458-2300
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OK6374101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)