Provider Demographics
NPI:1801592308
Name:DYNAMIC BEHAVIORAL HEALTHCARE SERVICES
Entity type:Organization
Organization Name:DYNAMIC BEHAVIORAL HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DICKSON
Authorized Official - Middle Name:D
Authorized Official - Last Name:OYEYEMI-KUTEYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-235-8869
Mailing Address - Street 1:2743 KENEDY LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0735
Mailing Address - Country:US
Mailing Address - Phone:817-235-8869
Mailing Address - Fax:
Practice Address - Street 1:2743 KENEDY LN
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-0735
Practice Address - Country:US
Practice Address - Phone:817-235-8869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-06
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX464166401Medicaid
TX467418601Medicaid