Provider Demographics
NPI:1487888046
Name:DYNAMIC PEDIATRIC THERAPY, INC.
Entity type:Organization
Organization Name:DYNAMIC PEDIATRIC THERAPY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ILEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-242-9424
Mailing Address - Street 1:15600 SW 288TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-1243
Mailing Address - Country:US
Mailing Address - Phone:305-242-9424
Mailing Address - Fax:305-400-0231
Practice Address - Street 1:15600 SW 288TH ST STE 202
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-1243
Practice Address - Country:US
Practice Address - Phone:305-242-9424
Practice Address - Fax:305-400-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 2081P0010X
FLOTA 10426224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation MedicineGroup - Multi-Specialty
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001392900Medicaid