MEDICARE: DIVERGENT PATH THERAPY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1417778101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERGENT PATH THERAPY, PLLC

Provider Business Mailing Address
First Line	:	3232 N HALSTED ST APT D403
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3487
Country	:	US
Telephone Number	:	872-228-9005
Fax Number	:

Provider Business Practice Location Address
First Line	:	3232 N HALSTED ST APT D403
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3487
Country	:	US
Telephone Number	:	872-228-9005
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	JULIA HOWARD
Credential	:	LCSW
Telephone Number	:	757-903-1246

Provider Enumeration Date	:	10/24/2024
Last Update Date	:	05/30/2026

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