Healthcare Provider Details

I. General information

NPI: 1265711998
Provider Name (Legal Business Name): DYNAMIC THERAPY SOLUTIONS AND DYSLEXIA CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2011
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 SIERRA COURT STE C-10
PALMDALE CA
93550
US

IV. Provider business mailing address

190 SIERRA COURT STE C-10
PALMDALE CA
93550
US

V. Phone/Fax

Practice location:
  • Phone: 661-274-8454
  • Fax: 661-274-7614
Mailing address:
  • Phone: 661-274-8454
  • Fax: 661-274-7614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP11463
License Number StateCA

VIII. Authorized Official

Name: MS. LISA CAROL SANDOVAL
Title or Position: SLP
Credential: SLP
Phone: 661-274-8454