Healthcare Provider Details

I. General information

NPI: 1942005830
Provider Name (Legal Business Name): DIVERGENT SHADES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2025
Last Update Date: 02/15/2025
Certification Date: 02/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 FAIR OAKS AVE STE 358
SOUTH PASADENA CA
91030-5812
US

IV. Provider business mailing address

625 FAIR OAKS AVE STE 358
SOUTH PASADENA CA
91030-5812
US

V. Phone/Fax

Practice location:
  • Phone: 626-460-6012
  • Fax:
Mailing address:
  • Phone: 626-460-6012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TARA FORD LEUFROY
Title or Position: PARTNER/OWNER/CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 818-369-9060