Healthcare Provider Details

I. General information

NPI: 1285329540
Provider Name (Legal Business Name): DIVERSE INTERVENTIONS SOCIAL AND BEHAVIORAL SCIENCES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SPORTSMAN PARK DR
SEFFNER FL
33584-4153
US

IV. Provider business mailing address

PO BOX 1526
SEFFNER FL
33583-1526
US

V. Phone/Fax

Practice location:
  • Phone: 813-531-5380
  • Fax:
Mailing address:
  • Phone: 813-531-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTINE LI'CHELE' MOORE
Title or Position: CEO
Credential: PHD
Phone: 813-531-5380