Provider Demographics
NPI:1477135739
Name:DIVERGILIO, ALEXANDER LOUIS (MED, NCC)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:LOUIS
Last Name:DIVERGILIO
Suffix:
Gender:M
Credentials:MED, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 GREEN MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-6504
Mailing Address - Country:US
Mailing Address - Phone:678-382-2732
Mailing Address - Fax:
Practice Address - Street 1:59 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1209
Practice Address - Country:US
Practice Address - Phone:678-423-4610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health