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General NPI Number Information
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NPI Number | 1225058001
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Entity Type | Organization
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Legal Business Name | DIVERSE VENTURES, LLC
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Dates
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Enumeration Date | 07/21/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 69 BELLERIVE ACRES
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City | SAINT LOUIS
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State | MO
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Zip | 63121-4330
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Country | US
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Telephone | 314-389-5007
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Fax | 314-389-6023
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Provider Business Mailing Address
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Address Line | 69 BELLERIVE ACRES
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City | SAINT LOUIS
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State | MO
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Zip | 63121-4330
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Country | US
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Telephone | 314-389-5007
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Fax | 314-389-6023
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST/OWNER
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Name | JAMECA FALCONER
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Credential | PHD
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Telephone | 314-495-2600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2006006565
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License Number State | MO
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