Healthcare Provider Details

I. General information

NPI: 1942358148
Provider Name (Legal Business Name): PAUL J DIVINCENZO PH.D
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5311 NORTHFIELD RD
BEDFORD HTS OH
44146-1135
US

IV. Provider business mailing address

5311 NORTHFIELD RD
BEDFORD HTS OH
44146-1135
US

V. Phone/Fax

Practice location:
  • Phone: 216-518-3900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3923
License Number StateOH

VIII. Authorized Official

Name: DR. PAUL JOHN DIVINCENZO
Title or Position: PRESIDENT
Credential:
Phone: 216-518-3900