Provider Demographics
NPI:1477372316
Name:DYNAMIC DUO SUPPORT LLC
Entity type:Organization
Organization Name:DYNAMIC DUO SUPPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/ OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-604-6117
Mailing Address - Street 1:1924 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08757-3619
Mailing Address - Country:US
Mailing Address - Phone:732-604-6117
Mailing Address - Fax:
Practice Address - Street 1:1924 2ND AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08757-3619
Practice Address - Country:US
Practice Address - Phone:732-604-6117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health