Provider Demographics
NPI:1477045995
Name:DYNAMIC PSYCHOLOGICAL & MEDIATION SERVICES
Entity Type:Organization
Organization Name:DYNAMIC PSYCHOLOGICAL & MEDIATION SERVICES
Other - Org Name:DYNAMIC PSYCHOLOGICAL & MEDIATION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GICHUKI
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:580-402-1696
Mailing Address - Street 1:311 GRANITE WASH
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-3649
Mailing Address - Country:US
Mailing Address - Phone:580-402-1696
Mailing Address - Fax:
Practice Address - Street 1:104 S 7TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601
Practice Address - Country:US
Practice Address - Phone:580-402-1696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6010101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty