Provider Demographics
NPI:1548719545
Name:DIVADIVERSITY
Entity type:Organization
Organization Name:DIVADIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:TICOULET
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:833-256-4225
Mailing Address - Street 1:1171 HOMESTEAD RD STE 220
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-5485
Mailing Address - Country:US
Mailing Address - Phone:833-256-4225
Mailing Address - Fax:408-904-7444
Practice Address - Street 1:1171 HOMESTEAD RD STE 220
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-5485
Practice Address - Country:US
Practice Address - Phone:833-256-4225
Practice Address - Fax:408-904-7444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-02
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty