Provider Demographics
NPI:1750359808
Name:DYNAMIC THERAPY ASSOCIATES, INC
Entity type:Organization
Organization Name:DYNAMIC THERAPY ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:678-521-4692
Mailing Address - Street 1:2841 PATCHES CT NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-5856
Mailing Address - Country:US
Mailing Address - Phone:678-521-4692
Mailing Address - Fax:
Practice Address - Street 1:3166 CHEROKEE ST NW
Practice Address - Street 2:SUITE 101
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2883
Practice Address - Country:US
Practice Address - Phone:678-521-4692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003536235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPR01733450001OtherCIGNA VENDOR NO.
GA52754489OtherBC/BS PROVIDER NO.