Healthcare Provider Details

I. General information

NPI: 1477045995
Provider Name (Legal Business Name): DYNAMIC PSYCHOLOGICAL & MEDIATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S 7TH ST
CLINTON OK
73601
US

IV. Provider business mailing address

311 GRANITE WASH
CLINTON OK
73601-3649
US

V. Phone/Fax

Practice location:
  • Phone: 580-402-1696
  • Fax:
Mailing address:
  • Phone: 580-402-1696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6010
License Number StateOK

VIII. Authorized Official

Name: JAMES GICHUKI
Title or Position: DIRECTOR/OWNER
Credential: MS, LPC
Phone: 580-402-1696