=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861003014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC ENGAGEMENT GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2020
-----------------------------------------------------
Last Update Date | 01/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 780 W LAKE LANSING RD STE 100
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48823-8452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-281-6359
-----------------------------------------------------
Fax | 517-323-9531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 780 W LAKE LANSING RD STE 100
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48823-8452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-281-6359
-----------------------------------------------------
Fax | 517-323-9531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | KILEY SHILLING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-258-2951
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------