Provider Demographics
NPI:1861126005
Name:DIVERSE BEHAVIORAL HEALTH GROUP
Entity type:Organization
Organization Name:DIVERSE BEHAVIORAL HEALTH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMM
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-471-5200
Mailing Address - Street 1:11971 N GRAND PKWY E STE 200207
Mailing Address - Street 2:
Mailing Address - City:NEW CANEY
Mailing Address - State:TX
Mailing Address - Zip Code:77357-1827
Mailing Address - Country:US
Mailing Address - Phone:346-471-5200
Mailing Address - Fax:346-474-0990
Practice Address - Street 1:18941 LAZZARO SPRINGS DR
Practice Address - Street 2:
Practice Address - City:ROMAN FOREST
Practice Address - State:TX
Practice Address - Zip Code:77357-2977
Practice Address - Country:US
Practice Address - Phone:346-471-5200
Practice Address - Fax:346-474-0990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX336059606Medicaid