Provider Demographics
NPI:1760490791
Name:GRAND LAKE MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:GRAND LAKE MENTAL HEALTH CENTER, INC.
Other - Org Name:GRAND LAKE MENTAL HEALTH CENTER, INC.-CRAIG COUNTY
Other - Org Type:Other Name
Authorized Official - Title/Position:MIS/REIMBURSEMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
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:918-256-6476
Mailing Address - Fax:918-256-3628
Practice Address - Street 1:405 E EXCELSIOR AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-4226
Practice Address - Country:US
Practice Address - Phone:918-256-6476
Practice Address - Fax:918-256-3628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management