=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093930687
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 07/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 S W S YOUNG DR STE 413
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76542-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-616-1676
-----------------------------------------------------
Fax | 254-616-1677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 S W S YOUNG DR STE 413
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76542-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 245-616-1676
-----------------------------------------------------
Fax | 254-616-1677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | JENNIFER KAYE CAYWOOD
-----------------------------------------------------
Credential | OTRL
-----------------------------------------------------
Telephone | 254-466-0740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 108369
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------