Provider Demographics
NPI:1174888408
Name:DYNAMIC ENGAGEMENT INSTITUTE, L3C
Entity type:Organization
Organization Name:DYNAMIC ENGAGEMENT INSTITUTE, L3C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:FOUTS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:802-388-3887
Mailing Address - Street 1:87 RIVERS BEND RD
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:VT
Mailing Address - Zip Code:05472-1101
Mailing Address - Country:US
Mailing Address - Phone:802-388-3887
Mailing Address - Fax:
Practice Address - Street 1:87 RIVERS BEND RD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:VT
Practice Address - Zip Code:05472-1101
Practice Address - Country:US
Practice Address - Phone:802-388-3887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0470084103261QD1600X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1020502Medicaid