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General NPI Number Information
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NPI Number | 1942005830
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Entity Type | Organization
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Legal Business Name | DIVERGENT SHADES
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Dates
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Enumeration Date | 02/15/2025
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Last Update Date | 02/15/2025
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Provider Practice Location Address
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Address Line | 625 FAIR OAKS AVE STE 358
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City | SOUTH PASADENA
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State | CA
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Zip | 91030-5812
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Country | US
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Telephone | 626-460-6012
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Fax |
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Provider Business Mailing Address
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Address Line | 625 FAIR OAKS AVE STE 358
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City | SOUTH PASADENA
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State | CA
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Zip | 91030-5812
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Country | US
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Telephone | 626-460-6012
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Fax |
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Authorized Official
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Title or Position | PARTNER/OWNER/CLINICAL PSYCHOLOGIST
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Name | TARA FORD LEUFROY
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Credential | PSYD
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Telephone | 818-369-9060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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