Provider Demographics
NPI:1598269615
Name:DYNAMIC KIDS THERAPY SERVICES
Entity Type:Organization
Organization Name:DYNAMIC KIDS THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CADET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-889-3349
Mailing Address - Street 1:5473 N HENRY BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-3261
Mailing Address - Country:US
Mailing Address - Phone:678-889-3349
Mailing Address - Fax:800-948-2944
Practice Address - Street 1:5473 N HENRY BLVD STE 4
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-3261
Practice Address - Country:US
Practice Address - Phone:678-889-3349
Practice Address - Fax:800-948-2944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003154352BMedicaid