Provider Demographics
NPI:1306039334
Name:DYNAMIC THERAPY CONCEPTS PLLC
Entity Type:Organization
Organization Name:DYNAMIC THERAPY CONCEPTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:270-705-5898
Mailing Address - Street 1:245 JENNIFER LYNN DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4861
Mailing Address - Country:US
Mailing Address - Phone:270-705-5898
Mailing Address - Fax:
Practice Address - Street 1:245 JENNIFER LYNN DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-4861
Practice Address - Country:US
Practice Address - Phone:270-705-5898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002256225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00454OtherMEDICARE GROUP
KYP00435045OtherMEDICARE RR - PTAN
KY1033121868OtherINDIVIDUAL NPI
11856022OtherCAQH
KYDG4266OtherMEDICARE RR - GROUP
KY7100057690Medicaid
KY000000551156OtherANTHEM BC & BS
KY1033121868OtherINDIVIDUAL NPI