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General NPI Number Information
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NPI Number | 1144926197
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Entity Type | Individual
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Provider Name | KERI DIVANIAN
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Gender | Female
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Dates
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Enumeration Date | 02/01/2023
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Last Update Date | 02/01/2023
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Provider Practice Location Address
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Address Line | 46 ROUTE 25A STE 3
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City | SETAUKET
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State | NY
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Zip | 11733-2806
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Country | US
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Telephone | 631-517-3345
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Fax |
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Provider Business Mailing Address
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Address Line | 19 BALLAD CIR
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City | HOLBROOK
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State | NY
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Zip | 11741-3808
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Country | US
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Telephone | 631-902-0192
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 115418
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License Number State | NY
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