Provider Demographics
NPI:1548915804
Name:DYNAMIC PATHWAYS, LCSW, PLLC
Entity type:Organization
Organization Name:DYNAMIC PATHWAYS, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:WHALEY
Authorized Official - Last Name:GUNDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-960-8575
Mailing Address - Street 1:600 JOHNSON AVE STE C13
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2674
Mailing Address - Country:US
Mailing Address - Phone:163-196-0857
Mailing Address - Fax:
Practice Address - Street 1:600 JOHNSON AVE STE C13
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2674
Practice Address - Country:US
Practice Address - Phone:631-960-8575
Practice Address - Fax:631-315-1090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health