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General NPI Number Information
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NPI Number | 1184173981
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Entity Type | Individual
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Provider Name | JEAN ELYSE DIEVENDORF
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Gender | Female
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Dates
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Enumeration Date | 09/22/2016
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Last Update Date | 02/14/2024
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Provider Practice Location Address
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Address Line | 6050 BABCOCK ST SE STE 32
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City | PALM BAY
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State | FL
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Zip | 32909-4205
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Country | US
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Telephone | 321-684-8265
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Fax |
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Provider Business Mailing Address
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Address Line | 2257 WHITESIDE AVE SE
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City | PALM BAY
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State | FL
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Zip | 32909-6044
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Country | US
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Telephone | 321-405-2583
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | SW16874
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW16874
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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