Provider Demographics
NPI:1265261010
Name:DYNAMIC BALANCE PSYCHOLOGY PLLC
Entity type:Organization
Organization Name:DYNAMIC BALANCE PSYCHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:RACHELLE
Authorized Official - Last Name:TENNYSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:208-373-0790
Mailing Address - Street 1:1505 SHAKESPEARE DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-8501
Mailing Address - Country:US
Mailing Address - Phone:360-360-5044
Mailing Address - Fax:
Practice Address - Street 1:1505 SHAKESPEARE DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8501
Practice Address - Country:US
Practice Address - Phone:360-360-5044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-30
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty