Basic Information
| Provider Information | |||||||||
| NPI: | 1801096623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAYSON | ||||||||
| FirstName: | SHARITTA | ||||||||
| MiddleName: | A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 NE 25TH CT | ||||||||
| Address2: | |||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731609552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059122632 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 S WASHITA AVE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730987820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056654385 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 10/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | Behavioral Health & Social Service Providers | Counselor | Professional | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 225C00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.