Provider Demographics
NPI:1265969166
Name:GROSSE, CALEB ALAN
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:ALAN
Last Name:GROSSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5628 N MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-1560
Mailing Address - Country:US
Mailing Address - Phone:828-593-8574
Mailing Address - Fax:
Practice Address - Street 1:4024 N LINCOLN BLVD # 220
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5207
Practice Address - Country:US
Practice Address - Phone:405-843-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty