Provider Demographics
NPI:1336475912
Name:JAMES DIVENS, ELIZABETH (MED)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JAMES DIVENS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:JAMES DIVENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED
Mailing Address - Street 1:184 DUDLEY STREET
Mailing Address - Street 2:SUITE 107LL
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119
Mailing Address - Country:US
Mailing Address - Phone:617-442-2002
Mailing Address - Fax:617-442-4002
Practice Address - Street 1:184 DUDLEY STREET
Practice Address - Street 2:SUITE 107LL
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119
Practice Address - Country:US
Practice Address - Phone:617-442-2002
Practice Address - Fax:617-442-4002
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health