Provider Demographics
NPI:1043929243
Name:DIVERGENCE MENTAL HEALTH GROUP LLC
Entity Type:Organization
Organization Name:DIVERGENCE MENTAL HEALTH GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:EDWARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:847-894-7288
Mailing Address - Street 1:4420 LYNDENWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80130-8807
Mailing Address - Country:US
Mailing Address - Phone:847-894-7288
Mailing Address - Fax:
Practice Address - Street 1:4420 LYNDENWOOD CIR
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80130-8807
Practice Address - Country:US
Practice Address - Phone:720-310-8786
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-16
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90000201368Medicaid