Basic Information
| Provider Information | |||||||||
| NPI: | 1063619286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYSON | ||||||||
| FirstName: | MIKE | ||||||||
| MiddleName: | DON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.P.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 E. ROBERT S. KERR BLVD. | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73098 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 S. WASHITA | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056654385 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 02/02/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.