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General NPI Number Information
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NPI Number | 1023656162
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Entity Type | Organization
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Legal Business Name | DYNAMIC POTENTIAL
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Dates
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Enumeration Date | 12/19/2019
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Last Update Date | 02/24/2020
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Provider Practice Location Address
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Address Line | 316 5TH ST STE 2
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City | RACINE
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State | WI
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Zip | 53403-4606
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Country | US
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Telephone | 262-308-8085
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1943
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City | KENOSHA
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State | WI
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Zip | 53141-1943
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Country | US
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Telephone | 262-308-8085
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. STEPHANIE R RASZKIEWICZ
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Credential | PHD
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Telephone | 262-308-8085
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TF0000X
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Taxonomy Name | Family Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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