Provider Demographics
NPI:1003543687
Name:DIVAD ZZEN THERAPY BOUTIQUE
Entity Type:Organization
Organization Name:DIVAD ZZEN THERAPY BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:856-807-5363
Mailing Address - Street 1:25 S HADDON AVE UNIT 104
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-8005
Mailing Address - Country:US
Mailing Address - Phone:856-807-5363
Mailing Address - Fax:
Practice Address - Street 1:321 YALE AVE STE B
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1247
Practice Address - Country:US
Practice Address - Phone:856-807-5363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty