Provider Demographics
NPI:1689702540
Name:FRAGOSO, GRICELDA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GRICELDA
Middle Name:
Last Name:FRAGOSO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 W 33RD ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3875
Mailing Address - Country:US
Mailing Address - Phone:405-309-9051
Mailing Address - Fax:
Practice Address - Street 1:1985 W 33RD ST
Practice Address - Street 2:SUITE 110
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3875
Practice Address - Country:US
Practice Address - Phone:405-309-9051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21847103TC0700X
OK1131103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10138OtherSAN DIEGO HHSA (EPSDT)