Provider Demographics
NPI:1205875093
Name:DYNAMIC THERAPY SERVICES, LLC
Entity type:Organization
Organization Name:DYNAMIC THERAPY SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TASHEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:PESC
Authorized Official - Phone:252-248-3313
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:252-248-3313
Mailing Address - Fax:
Practice Address - Street 1:350 NEW FIDELITY CT
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-2665
Practice Address - Country:US
Practice Address - Phone:919-258-2714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2024-12-19
Deactivation Date:2024-12-09
Deactivation Code:
Reactivation Date:2024-12-19
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1836333OtherHIGHMARK PABS
PA2158175OtherHIGHMARK PABS
50065703OtherCBC
MD6089003Medicaid
PA1022275170001Medicaid
PA1160732OtherKMHP
235020OtherUNISON
DE3739248000OtherIBC PC
MD01284117OtherAMERIGROUP
MDAA44-0000OtherCAREFIRST
DE1205875093Medicaid
DE2158186OtherBCBS DE
DE2519840OtherBCBS DE
PA2835283000OtherIBC PC
235020OtherUNISON
50065703OtherCBC
DEDF3674Medicare PIN
PA1836333OtherHIGHMARK PABS
MD01284117OtherAMERIGROUP
MD358157Medicare UPIN
PADO2995Medicare PIN