Organization
GRAND LAKE THERAPEUTICS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MITZY KANTOR LPC (OWNER)
(918) 786-0875
Entity
Organization
Contact information
Practice address
1441 LAKESIDE DR, GROVE, OK 74344-4223
(918) 786-0875
Mailing address
1441 LAKESIDE DR, GROVE, OK 74344-4223
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
—
—
Other
Enumeration date
08/24/2020
Last updated
08/24/2020
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