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General NPI Number Information
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NPI Number | 1184063430
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Entity Type | Organization
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Legal Business Name | DYNAMIC YOUTH SUPPORT SERVICES, LLC
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Dates
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Enumeration Date | 06/20/2013
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Last Update Date | 06/20/2013
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Provider Practice Location Address
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Address Line | 823 W CENTRAL BLVD
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City | ORLANDO
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State | FL
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Zip | 32805-1808
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Country | US
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Telephone | 407-347-7396
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 550116
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City | ORLANDO
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State | FL
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Zip | 32855-0116
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Country | US
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Telephone | 407-347-7396
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. DANTE LEVELL JOHNSON
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Credential |
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Telephone | 407-770-7611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 03802013876
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License Number State | FL
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