Provider Demographics
NPI:1598365942
Name:DIVERSIFIED BEHAVIORAL HEALTH, A PROFESSIONAL CLINICAL COUNSELOR CORPO
Entity type:Organization
Organization Name:DIVERSIFIED BEHAVIORAL HEALTH, A PROFESSIONAL CLINICAL COUNSELOR CORPO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BORING-BRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-842-8595
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-0224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26040 ACERO STE 207
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2768
Practice Address - Country:US
Practice Address - Phone:949-842-8595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-26
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1699028134OtherNPPES