Healthcare Provider Details

I. General information

NPI: 1508555970
Provider Name (Legal Business Name): DYNAMIC ABILITIES PEDIATRIC THERAPY: OCCUPATIONAL AND PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 BOARDWALK STE 204
SAN MARCOS CA
92078-2600
US

IV. Provider business mailing address

950 BOARDWALK STE 204
SAN MARCOS CA
92078-2600
US

V. Phone/Fax

Practice location:
  • Phone: 760-383-3278
  • Fax: 760-502-1474
Mailing address:
  • Phone: 760-383-3278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DONNA MARMOLEJO
Title or Position: PRESIDENT/CHIEF EXECUTIVE OFFICER
Credential: PT, DPT
Phone: 760-383-3278