=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942793252
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC INTERVENTION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2018
-----------------------------------------------------
Last Update Date | 08/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 MARKET ST
-----------------------------------------------------
City | WAPPINGERS FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12590-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-702-1042
-----------------------------------------------------
Fax | 845-709-8434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 MARKET ST
-----------------------------------------------------
City | WAPPINGERS FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12590-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-702-1042
-----------------------------------------------------
Fax | 845-709-8434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JACQUELINE B MULLER
-----------------------------------------------------
Credential | LCSW-R
-----------------------------------------------------
Telephone | 845-702-1042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R056489
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------