Provider Demographics
NPI:1629746615
Name:DYNAMIC HEALTH THERAPY
Entity Type:Organization
Organization Name:DYNAMIC HEALTH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LACY
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:801-643-2303
Mailing Address - Street 1:1190 E 5425 S STE 210
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5194
Mailing Address - Country:US
Mailing Address - Phone:385-400-9193
Mailing Address - Fax:
Practice Address - Street 1:1190 E 5425 S STE 210
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5194
Practice Address - Country:US
Practice Address - Phone:385-400-9193
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty