Provider Demographics
NPI:1104554864
Name:DIVERGENT RECOVERY LLC
Entity type:Organization
Organization Name:DIVERGENT RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-336-0507
Mailing Address - Street 1:8140 W MISSION LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-4829
Mailing Address - Country:US
Mailing Address - Phone:480-336-0507
Mailing Address - Fax:
Practice Address - Street 1:15655 W ROOSEVELT ST STE 100
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9311
Practice Address - Country:US
Practice Address - Phone:480-336-0507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health