Grand Lake Therapeutics LLC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

Legal business name

GRAND LAKE THERAPEUTICS LLC

Practice address

1441 Lakeside Dr
Grove, OK 74344-4223

Phone

(918) 786-0875

NPI assigned

Aug 24, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mitzy Kantor, LPCNPI 1306256235

Title

Owner

Phone

(918) 786-0875

Specialties & licenses 1

Addresses

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Mitzy Kantor

  • Addiction (Substance Use Disorder) Counselor
  • Claremore, OK
  • NPI 1306256235
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1598227200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598227200000",
    "number": "1528670239",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1441 LAKESIDE DR",
            "city": "GROVE",
            "state": "OK",
            "postal_code": "743444223"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1441 LAKESIDE DR",
            "city": "GROVE",
            "state": "OK",
            "postal_code": "743444223",
            "telephone_number": "918-786-0875"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRAND LAKE THERAPEUTICS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-08-24",
        "last_updated": "2020-08-24",
        "certification_date": "2020-08-24",
        "status": "A",
        "authorized_official_last_name": "KANTOR",
        "authorized_official_first_name": "MITZY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "918-786-0875",
        "authorized_official_credential": "LPC"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Grand Lake Mental Health Center, Inc.
• Grand Lake Mental Health Center, Inc.
• Grand Lake Mental Health Center, Inc.
• Grand Lake Optical, LLC
• Grand Lake Regional Cardiology Services LLC
• Grand Lake Villa LLC
• Grandwood Assisted Living, LC
• Christopher Gray, NP
• Sarah Green, MSW
• Joseph Gregory, APRN

• All providers in Grove, OK
• Professional Counselor in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 24, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.