Healthcare Provider Details

I. General information

NPI: 1043045941
Provider Name (Legal Business Name): DIVE THERAPY & CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 HOWELL MILL RD NW FL 8
ATLANTA GA
30318-5557
US

IV. Provider business mailing address

1700 NORTHSIDE DR NW STE A7, PMB 1704
ATLANTA GA
30318-2695
US

V. Phone/Fax

Practice location:
  • Phone: 404-800-1998
  • Fax: 404-393-0989
Mailing address:
  • Phone: 404-800-1998
  • Fax: 404-393-0989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. SPESHAL T.W. GAUTIER
Title or Position: OWNER
Credential: PHD
Phone: 404-800-1998