Provider Demographics
NPI:1073878807
Name:DYNAMIC FUNCTION THERAPY SERVICES, PLLC
Entity Type:Organization
Organization Name:DYNAMIC FUNCTION THERAPY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:T
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OTL
Authorized Official - Phone:605-490-1554
Mailing Address - Street 1:3140 E FOX ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-5418
Mailing Address - Country:US
Mailing Address - Phone:605-490-1554
Mailing Address - Fax:480-634-6442
Practice Address - Street 1:3140 E FOX ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5418
Practice Address - Country:US
Practice Address - Phone:605-490-1554
Practice Address - Fax:480-634-6442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4587225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1740329887OtherINDIVIDUAL NPI #