Basic Information
| Provider Information | |||||||||
| NPI: | 1205875093 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DYNAMIC THERAPY SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PIVOT PHYSICAL THERAPY OF MID ATLANTIC, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 FAIRMOUNT AVE STE 302 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108854607 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 350 NEW FIDELITY CT | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275292665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192582714 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PEARSON | ||||||||
| AuthorizedOfficialFirstName: | PENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DRCM | ||||||||
| AuthorizedOfficialTelephone: | 4432254492 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1022275170001 | 05 | PA | MEDICAID | 01284117 | 01 | MD | AMERIGROUP | OTHER | 2835283000 | 01 | PA | IBC PC | OTHER | 3739248000 | 01 | DE | IBC PC | OTHER | 2158186 | 01 | DE | BCBS DE | OTHER | 235020 | 01 | UNISON | OTHER | 2158175 | 01 | PA | HIGHMARK PABS | OTHER | 2519840 | 01 | DE | BCBS DE | OTHER | 1205875093 | 05 | DE | MEDICAID | 6089003 | 05 | MD | MEDICAID | AA44-0000 | 01 | MD | CAREFIRST | OTHER | 1160732 | 01 | PA | KMHP | OTHER | 1836333 | 01 | PA | HIGHMARK PABS | OTHER | 50065703 | 01 | CBC | OTHER |