Healthcare Provider Details

I. General information

NPI: 1548743024
Provider Name (Legal Business Name): DYNAMIC WELLNESS SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 NE 26TH ST STE 201A
WILTON MANORS FL
33305-1427
US

IV. Provider business mailing address

1881 NE 26TH ST STE 201A
WILTON MANORS FL
33305-1427
US

V. Phone/Fax

Practice location:
  • Phone: 195-436-8581
  • Fax:
Mailing address:
  • Phone: 195-436-8581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GRACE MARQUEZ
Title or Position: OWNER/CHIEF EXECUTIVE OFFICER
Credential: LMHC, MCAP
Phone: 954-368-5819