Provider Demographics
NPI:1275702813
Name:DYNAMIC POTENTIAL, L.C.
Entity Type:Organization
Organization Name:DYNAMIC POTENTIAL, L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIETH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:D MIN
Authorized Official - Phone:305-662-2173
Mailing Address - Street 1:1550 MADRUGA AVENUE
Mailing Address - Street 2:SUITE 331
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-3071
Mailing Address - Country:US
Mailing Address - Phone:305-662-2173
Mailing Address - Fax:305-662-2668
Practice Address - Street 1:1550 MADRUGA AVE
Practice Address - Street 2:SUITE 331
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-3039
Practice Address - Country:US
Practice Address - Phone:305-662-2173
Practice Address - Fax:305-662-2668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH1964101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty