Provider Demographics
NPI:1386740439
Name:DIVINCENZO, PAUL JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JOHN
Last Name:DIVINCENZO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 HILLCREEK LN
Mailing Address - Street 2:
Mailing Address - City:GATES MILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44040-9630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5311 NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:BEDFORD HTS
Practice Address - State:OH
Practice Address - Zip Code:44146-1135
Practice Address - Country:US
Practice Address - Phone:216-518-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3923103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0443756Medicaid