Healthcare Provider Details

I. General information

NPI: 1255858775
Provider Name (Legal Business Name): DYNAMIC THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 N UNION ST STE 101
WILMINGTON DE
19805-3431
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 302-778-0810
  • Fax: 302-778-0812
Mailing address:
  • Phone: 252-248-3313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: TASHEDA BROUGHTON
Title or Position: MANAGER, CREDENTIALING
Credential: PESC
Phone: 252-248-3313