1669715447 NPI number — DYNAMIC BEHAVIORAL SERVICES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669715447 NPI number — DYNAMIC BEHAVIORAL SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC BEHAVIORAL SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669715447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1605 SIDENER HALL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATHAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62629-2401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-381-8487
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1605 SIDENER HALL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATHAM
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62629-2401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-381-8487
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2013

Additional Information

Authorized Official

Authorized Official Last Name:
AFFRUNTI
Authorized Official First Name:
DANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/BEHAVIOR ANALYST
Authorized Official Telephone Number:
217-381-8487

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-09-6575 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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