Provider Demographics
NPI:1962221119
Name:COGDIVERSIFIED
Entity type:Organization
Organization Name:COGDIVERSIFIED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIANJIAO
Authorized Official - Middle Name:
Authorized Official - Last Name:SUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-376-8348
Mailing Address - Street 1:2022 VANCOUVER AVE # A
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-5908
Mailing Address - Country:US
Mailing Address - Phone:571-376-8348
Mailing Address - Fax:
Practice Address - Street 1:2022 VANCOUVER AVE # A
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-5908
Practice Address - Country:US
Practice Address - Phone:571-376-8348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-05
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty