Provider Demographics
NPI:1528484409
Name:DYNAMIC WAVES OF CHANGE
Entity type:Organization
Organization Name:DYNAMIC WAVES OF CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAMOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-916-8818
Mailing Address - Street 1:3700 SW 54TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-5670
Mailing Address - Country:US
Mailing Address - Phone:305-916-8818
Mailing Address - Fax:305-705-3236
Practice Address - Street 1:2020 NE 163RD ST
Practice Address - Street 2:#204
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4927
Practice Address - Country:US
Practice Address - Phone:786-345-1510
Practice Address - Fax:305-705-3236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-15
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAP 4003101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty