Healthcare Provider Details

I. General information

NPI: 1356982516
Provider Name (Legal Business Name): DYNAMIC COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 S OLIVER ST
WICHITA KS
67218-2351
US

IV. Provider business mailing address

615 S HOLYOKE ST
WICHITA KS
67218-1904
US

V. Phone/Fax

Practice location:
  • Phone: 316-734-6237
  • Fax:
Mailing address:
  • Phone: 316-734-6237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: DELVON STALEY
Title or Position: COUNSELING DIRECTOR/OWNER
Credential:
Phone: 316-734-6237