Provider Demographics
NPI:1023656162
Name:DYNAMIC POTENTIAL
Entity type:Organization
Organization Name:DYNAMIC POTENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:RASZKIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-308-8085
Mailing Address - Street 1:PO BOX 1943
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53141-1943
Mailing Address - Country:US
Mailing Address - Phone:262-308-8085
Mailing Address - Fax:
Practice Address - Street 1:316 5TH ST STE 2
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-4606
Practice Address - Country:US
Practice Address - Phone:262-308-8085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-19
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40968000Medicaid