| Grand Lake Therapeutics Llc | |
|
1441 Lakeside Dr Grove OK 74344-4223 | |
| (918) 786-0875 | |
| Not Available |
| Full Name | Grand Lake Therapeutics Llc |
|---|---|
| Speciality | Counselor - Professional |
| Location | 1441 Lakeside Dr, Grove, Oklahoma |
| Authorized Official Name and Position | Mitzy Kantor (OWNER) |
| Authorized Official Contact | 9187860875 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Grand Lake Therapeutics Llc 1441 Lakeside Dr Grove OK 74344-4223 Ph: () - | Grand Lake Therapeutics Llc 1441 Lakeside Dr Grove OK 74344-4223 Ph: (918) 786-0875 |
| NPI Number | 1528670239 |
|---|---|
| Provider Enumeration Date | 08/24/2020 |
| Last Update Date | 08/24/2020 |
| Certification Date | 08/24/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1528670239 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | (* (Not Available)) | Primary |
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