1205875093 NPI number — DYNAMIC THERAPY SERVICES, LLC

Table of content: MISS DARA FAYE POWELL BS (NPI 1982958294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205875093 NPI number — DYNAMIC THERAPY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC THERAPY SERVICES, LLC
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:
6
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:
1205875093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
12/09/2024
NPI Reactivation Date:
12/19/2024

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2122 YORK RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-1925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-248-3313
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 NEW FIDELITY CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARNER
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27529-2665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-258-2714
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRANADOS
Authorized Official First Name:
JUANA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, CREDENTIALING
Authorized Official Telephone Number:
630-575-1980

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1836333 . This is a "HIGHMARK PABS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1160732 . This is a "KMHP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2158175 . This is a "HIGHMARK PABS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2158186 . This is a "BCBS DE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2519840 . This is a "BCBS DE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 50065703 . This is a "CBC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2835283000 . This is a "IBC PC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: AA44-0000 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1205875093 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3739248000 . This is a "IBC PC" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 6089003 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01284117 . This is a "AMERIGROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1022275170001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 235020 . This is a "UNISON" identifier . This identifiers is of the category "OTHER".




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