MEDICARE: DIVERSIFIED PSYCHOTHERAPY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS 21160	CA

General Provider Information

NPI Number	:	1215061072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSIFIED PSYCHOTHERAPY INC

Provider Business Mailing Address
First Line	:	PO BOX 191
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90714-0191
Country	:	US
Telephone Number	:	562-743-2789
Fax Number	:	562-421-1496

Provider Business Practice Location Address
First Line	:	5199 E PACIFIC COAST HWY
Second Line	:	SUITE 615
City	:	LONG BEACH
State	:	CA
Zip	:	90804-3302
Country	:	US
Telephone Number	:	562-743-2789
Fax Number	:	562-743-2789

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL NAVA
Credential	:	L.C.S.W.
Telephone Number	:	562-743-2789

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	08/22/2020

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