Provider Demographics
NPI:1659695831
Name:DYNAMIC HEALTHCARE PROVIDERS
Entity Type:Organization
Organization Name:DYNAMIC HEALTHCARE PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, PHD
Authorized Official - Phone:954-202-9334
Mailing Address - Street 1:2901 W OAKLAND PARK BLVD
Mailing Address - Street 2:#A1
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1243
Mailing Address - Country:US
Mailing Address - Phone:954-202-9334
Mailing Address - Fax:954-202-7912
Practice Address - Street 1:2901 W OAKLAND PARK BLVD
Practice Address - Street 2:#A1
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1243
Practice Address - Country:US
Practice Address - Phone:954-202-9334
Practice Address - Fax:954-202-7912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3876251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL676033396Medicaid
FL676033398Medicaid