Provider Demographics
NPI:1457827016
Name:GRUNDY PSYCHOLOGICAL SERVICES, P.C.
Entity Type:Organization
Organization Name:GRUNDY PSYCHOLOGICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:MOLLETTE
Authorized Official - Last Name:GRUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:918-855-8315
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:OK
Mailing Address - Zip Code:74349-0006
Mailing Address - Country:US
Mailing Address - Phone:918-629-8664
Mailing Address - Fax:918-782-4301
Practice Address - Street 1:205 KETCHUM AVENUE
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:OK
Practice Address - Zip Code:74349
Practice Address - Country:US
Practice Address - Phone:918-629-8664
Practice Address - Fax:918-782-4301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100839060AMedicaid
OK100838100AMedicaid