Provider Demographics
NPI:1821743113
Name:DYNAMIC CHILD
Entity Type:Organization
Organization Name:DYNAMIC CHILD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:REGAN
Authorized Official - Middle Name:HILLEBRECHT
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:COTA/L
Authorized Official - Phone:860-310-8676
Mailing Address - Street 1:64 LAMB RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-3313
Mailing Address - Country:US
Mailing Address - Phone:860-310-8676
Mailing Address - Fax:
Practice Address - Street 1:175 HARTFORD TURNPIKE
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084
Practice Address - Country:US
Practice Address - Phone:860-310-8676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1114431038Medicaid
CT1134593247Medicaid
CT1225363070Medicaid