Provider Demographics
NPI:1881087641
Name:DYNAMIC THERAPEUTIC & MENTAL BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:DYNAMIC THERAPEUTIC & MENTAL BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:U
Authorized Official - Last Name:UBOZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-202-6242
Mailing Address - Street 1:500 N MERIDIAN AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-5706
Mailing Address - Country:US
Mailing Address - Phone:405-202-6242
Mailing Address - Fax:
Practice Address - Street 1:500 N MERIDIAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-5706
Practice Address - Country:US
Practice Address - Phone:405-202-6242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty