Healthcare Provider Details

I. General information

NPI: 1700579943
Provider Name (Legal Business Name): DIVERSITY OUTREACH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 FOLLY MILL RD UNIT B
SEABROOK NH
03874-4016
US

IV. Provider business mailing address

122 FOLLY MILL RD UNIT B
SEABROOK NH
03874-4016
US

V. Phone/Fax

Practice location:
  • Phone: 603-401-8489
  • Fax:
Mailing address:
  • Phone: 603-401-8489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. DONNA QUINN CORRIVEAU
Title or Position: OWNER - MANAGER- PROVIDER
Credential:
Phone: 603-401-8489