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NPI Code Detail

MEDICARE: DIVADIVERSITY

MEDICARE: DIVADIVERSITY
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
1101YM0800XMental Health Counselor
2103TC0700XClinical Psychologist
3106H00000XMarriage & Family Therapist

General Provider Information

NPI Number : 1548719545
Entity Type Code : Organization
Provider Name (Legal Business Name) : DIVADIVERSITY
Provider Business Mailing Address
First Line : 1171 HOMESTEAD RD STE 220
Second Line :
City : SANTA CLARA
State : CA
Zip : 95050-5485
Country : US
Telephone Number : 833-256-4225
Fax Number : 408-904-7444
Provider Business Practice Location Address
First Line : 1171 HOMESTEAD RD STE 220
Second Line :
City : SANTA CLARA
State : CA
Zip : 95050-5485
Country : US
Telephone Number : 833-256-4225
Fax Number : 408-904-7444
Authorized Official
Title or Position : CEO
Name : ARLENE TICOULET
Credential : LMFT
Telephone Number : 833-256-4225
Provider Enumeration Date : 10/02/2016
Last Update Date : 03/31/2020

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Directions to “DIVADIVERSITY ” Practice Location

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