Provider Demographics
NPI:1003843442
Name:DYNAMIC THERAPY, INC.
Entity Type:Organization
Organization Name:DYNAMIC THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:CREDLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:919-363-5000
Mailing Address - Street 1:2920 RIDGEPINE DR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-7934
Mailing Address - Country:US
Mailing Address - Phone:919-363-5000
Mailing Address - Fax:919-363-5346
Practice Address - Street 1:2920 RIDGEPINE DR
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-7934
Practice Address - Country:US
Practice Address - Phone:919-363-5000
Practice Address - Fax:919-353-5346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13112251P0200X
NC21522251P0200X
NC22152251P0200X
NC37862251P0200X
NC5261225XP0200X
NC4215225XP0200X
NC4734225XP0200X
NC6426235Z00000X
NC6205235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7210370Medicaid
NC7201106Medicaid
NC7211723Medicaid
NC7207861Medicaid
NC7210194Medicaid
NC7301807Medicaid
NC8300158Medicaid
NC7201000Medicaid
NC7207890Medicaid
NC731037UMedicaid
NC7412015Medicaid