Provider Demographics
NPI:1578154720
Name:GRASS, SAVANNAH
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:GRASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20210 EAST ADMIRAL PL APT 328
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015
Mailing Address - Country:US
Mailing Address - Phone:918-497-0286
Mailing Address - Fax:
Practice Address - Street 1:6333 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135
Practice Address - Country:US
Practice Address - Phone:918-664-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-31
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)