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General NPI Number Information
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NPI Number | 1689409955
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Entity Type | Organization
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Legal Business Name | DIVERGE COUNSELING LLC
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Dates
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Enumeration Date | 09/05/2024
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Last Update Date | 09/05/2024
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Provider Practice Location Address
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Address Line | 2800 W 21ST ST STE 102
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City | ERIE
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State | PA
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Zip | 16506-2980
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Country | US
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Telephone | 814-900-4562
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Fax | 814-731-6496
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Provider Business Mailing Address
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Address Line | 2800 W 21ST ST STE 102
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City | ERIE
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State | PA
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Zip | 16506-2980
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Country | US
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Telephone | 814-900-4562
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Fax | 814-731-6496
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Authorized Official
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Title or Position | OWNER
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Name | MADELYN SIMMONS
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Credential | LPC, ATR
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Telephone | 814-900-4562
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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