Provider Demographics
NPI:1558653444
Name:DIVERSE RECOVERY
Entity Type:Organization
Organization Name:DIVERSE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:832-984-1868
Mailing Address - Street 1:3130 STRAWBERRY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77504-1767
Mailing Address - Country:US
Mailing Address - Phone:832-984-1868
Mailing Address - Fax:
Practice Address - Street 1:3130 STRAWBERRY RD
Practice Address - Street 2:SUITE C
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-1767
Practice Address - Country:US
Practice Address - Phone:832-984-1868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder