Healthcare Provider Details

I. General information

NPI: 1639754542
Provider Name (Legal Business Name): DIAMOND BROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 07/19/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 BEAVER RUIN RD STE 500
NORCROSS GA
30093-2813
US

IV. Provider business mailing address

547 EAST AVE NE
ATLANTA GA
30312-1346
US

V. Phone/Fax

Practice location:
  • Phone: 855-772-8847
  • Fax:
Mailing address:
  • Phone: 833-747-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: