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General NPI Number Information
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NPI Number | 1912299173
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Entity Type | Organization
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Legal Business Name | DIVERSE WELLNESS SOLUTIONS INC
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Dates
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Enumeration Date | 05/06/2011
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Last Update Date | 01/06/2016
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Provider Practice Location Address
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Address Line | 7155 SUNSET LAKE RD
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City | FUQUAY VARINA
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State | NC
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Zip | 27526-8638
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Country | US
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Telephone | 919-838-0804
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Fax | 919-838-1219
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Provider Business Mailing Address
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Address Line | 7155 SUNSET LAKE RD
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City | FUQUAY VARINA
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State | NC
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Zip | 27526-8638
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Country | US
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Telephone | 919-838-0804
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Fax | 919-838-1219
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MRS. KIMBALL JANE-MARIE SARGENT
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Credential | MSN, PMHCNS-BC
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Telephone | 919-838-0804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 0261495-01
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 0261495-01
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 364SP0808X
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Taxonomy Name | Psychiatric/Mental Health Clinical Nurse Specialist
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License Number | 0261495-01
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License Number State | NC
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