Provider Demographics
NPI:1144926197
Name:DIVANIAN, KERI
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:
Last Name:DIVANIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BALLAD CIR
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-3808
Mailing Address - Country:US
Mailing Address - Phone:631-902-0192
Mailing Address - Fax:
Practice Address - Street 1:46 ROUTE 25A STE 3
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2806
Practice Address - Country:US
Practice Address - Phone:631-517-3345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115418104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker