MEDICARE: DYNAMIC ENGAGEMENT INSTITUTE, L3C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD1600X	Developmental Disabilities Clinic/Center	0470084103	VT
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center	0470084103	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174888408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC ENGAGEMENT INSTITUTE, L3C

Provider Business Mailing Address
First Line	:	87 RIVERS BEND RD
Second Line	:
City	:	NEW HAVEN
State	:	VT
Zip	:	05472-1101
Country	:	US
Telephone Number	:	802-388-3887
Fax Number	:

Provider Business Practice Location Address
First Line	:	87 RIVERS BEND RD
Second Line	:
City	:	NEW HAVEN
State	:	VT
Zip	:	05472-1101
Country	:	US
Telephone Number	:	802-388-3887
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	MICHELE AARON FOUTS
Credential	:	MA
Telephone Number	:	802-388-3887

Provider Enumeration Date	:	07/12/2012
Last Update Date	:	07/12/2012

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