Provider Demographics
NPI:1598216087
Name:GRAND LAKE MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:GRAND LAKE MENTAL HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-273-1841
Mailing Address - Street 1:114 W DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-2601
Mailing Address - Country:US
Mailing Address - Phone:918-273-1841
Mailing Address - Fax:918-273-1843
Practice Address - Street 1:1010 HARBER RD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-5147
Practice Address - Country:US
Practice Address - Phone:918-786-4434
Practice Address - Fax:918-786-4435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)