Provider Demographics
NPI:1043431489
Name:DIVERSIFIED PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:DIVERSIFIED PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:C
Authorized Official - Last Name:KNOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-238-9553
Mailing Address - Street 1:PO BOX 9062
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-9062
Mailing Address - Country:US
Mailing Address - Phone:903-238-9553
Mailing Address - Fax:
Practice Address - Street 1:1508 W FAIRMONT ST
Practice Address - Street 2:SUITE C
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-6303
Practice Address - Country:US
Practice Address - Phone:903-238-9553
Practice Address - Fax:903-291-8709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00145NOtherBLUE CROSS BLUE SHIELD
TX079990001Medicaid
TX00145NOtherBLUE CROSS BLUE SHIELD