Provider Demographics
NPI:1639450034
Name:INNER DYNAMICS, LLC
Entity Type:Organization
Organization Name:INNER DYNAMICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFORTE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:386-313-6166
Mailing Address - Street 1:1 RYBARK PL
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-6440
Mailing Address - Country:US
Mailing Address - Phone:386-313-6166
Mailing Address - Fax:386-313-6166
Practice Address - Street 1:50 LEANNI WAY
Practice Address - Street 2:SUITE B-3
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4751
Practice Address - Country:US
Practice Address - Phone:386-313-6166
Practice Address - Fax:386-313-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW96141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDD834ZMedicare PIN