Provider Demographics
NPI:1548743024
Name:DYNAMIC WELLNESS SOLUTIONS, LLC
Entity Type:Organization
Organization Name:DYNAMIC WELLNESS SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, MCAP
Authorized Official - Phone:954-368-5819
Mailing Address - Street 1:1881 NE 26TH ST STE 201A
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1427
Mailing Address - Country:US
Mailing Address - Phone:195-436-8581
Mailing Address - Fax:
Practice Address - Street 1:1881 NE 26TH ST STE 201A
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-1427
Practice Address - Country:US
Practice Address - Phone:195-436-8581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health