Provider Demographics
NPI:1033940614
Name:DIVERGENT NEUROPSYCHOLOGICAL ASSESS
Entity type:Organization
Organization Name:DIVERGENT NEUROPSYCHOLOGICAL ASSESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER/NEUROPSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:469-487-7911
Mailing Address - Street 1:713 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-2982
Mailing Address - Country:US
Mailing Address - Phone:469-487-7911
Mailing Address - Fax:
Practice Address - Street 1:713 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-2982
Practice Address - Country:US
Practice Address - Phone:469-487-7911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty