Healthcare Provider Details

I. General information

NPI: 1619716404
Provider Name (Legal Business Name): RECLAIMED DIVERGENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4790 RED BANK RD STE 216
CINCINNATI OH
45227-1509
US

IV. Provider business mailing address

4790 RED BANK RD STE 216
CINCINNATI OH
45227-1509
US

V. Phone/Fax

Practice location:
  • Phone: 513-900-2016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name: EMILEY MORTON
Title or Position: CO-OWNER
Credential: DSW
Phone: 859-559-3741