Healthcare Provider Details

I. General information

NPI: 1831355155
Provider Name (Legal Business Name): DYNAMIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 S VAUGHN DRIVE SUITE F
BRUSLY LA
70719
US

IV. Provider business mailing address

309 S VAUGHN DRIVE SUITE F
BRUSLY LA
70719
US

V. Phone/Fax

Practice location:
  • Phone: 225-749-2065
  • Fax: 225-749-2427
Mailing address:
  • Phone: 225-749-2065
  • Fax: 225-749-2427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01005
License Number StateLA

VIII. Authorized Official

Name: SHERALYN K CALLIHAN-FAVROT
Title or Position: PT/OWNER
Credential: PT
Phone: 225-749-2065