Grand Lake Therapeutics LLC

NPI #1528670239 in Grove, Oklahoma

Provider Information

NPI Number: 1528670239
Entity Type: Organization
Organization Name: Grand Lake Therapeutics LLC
Primary Specialty: Counselor - Professional
Enumeration Date: Aug 24, 2020
Last Updated: Aug 24, 2020

Practice Location

Address: 1441 LAKESIDE DR
City: Grove
State: Oklahoma
ZIP Code: 74344-4223
Phone: (918) 786-0875

Authorized Official

Name: MITZY KANTOR, LPC
Title: OWNER
Phone: (918) 786-0875

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Counselor - Professional — Professional	101YP2500X	Primary

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