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General NPI Number Information
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NPI Number | 1477045995
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Entity Type | Organization
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Legal Business Name | DYNAMIC PSYCHOLOGICAL & MEDIATION SERVICES
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Dates
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Enumeration Date | 05/31/2018
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Last Update Date | 05/31/2018
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Provider Practice Location Address
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Address Line | 104 S 7TH ST
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City | CLINTON
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State | OK
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Zip | 73601
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Country | US
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Telephone | 580-402-1696
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Fax |
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Provider Business Mailing Address
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Address Line | 311 GRANITE WASH
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City | CLINTON
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State | OK
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Zip | 73601-3649
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Country | US
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Telephone | 580-402-1696
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Fax |
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Authorized Official
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Title or Position | DIRECTOR/OWNER
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Name | JAMES GICHUKI
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Credential | MS, LPC
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Telephone | 580-402-1696
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6010
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License Number State | OK
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