Organization
DYNAMIC THERAPY ASSOCIATES, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. VICKI K CLARKE M.S. CCC-SLP (PRESIDENT)
(678) 521-4692
Entity
Organization
Contact information
Practice address
3166 CHEROKEE ST NW, SUITE 101, KENNESAW, GA 30144-2883
(678) 521-4692
Mailing address
2841 PATCHES CT NW, KENNESAW, GA 30152-5856
(678) 521-4692
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
003536
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
52754489
BC/BS PROVIDER NO.
GA
01
—
PR01733450001
CIGNA VENDOR NO.
TN
Enumeration date
03/14/2006
Last updated
08/22/2020
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