Basic Information
| Provider Information | |||||||||
| NPI: | 1861003014 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DYNAMIC ENGAGEMENT GROUP LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LINDSAY GROSS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 W LAKE LANSING RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488238452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172816359 | ||||||||
| FaxNumber: | 5173239531 | ||||||||
| Practice Location | |||||||||
| Address1: | 780 W LAKE LANSING RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488238452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172816359 | ||||||||
| FaxNumber: | 5173239531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2020 | ||||||||
| LastUpdateDate: | 01/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHILLING | ||||||||
| AuthorizedOfficialFirstName: | KILEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5172582951 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1780954180 | 05 | MI | MEDICAID |