Provider Demographics
NPI:1629082532
Name:DIVERDE-NUSHAWG, NANCY ANNE (PSYD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ANNE
Last Name:DIVERDE-NUSHAWG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 E PORT AU PRINCE LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3667
Mailing Address - Country:US
Mailing Address - Phone:602-368-7005
Mailing Address - Fax:602-368-7005
Practice Address - Street 1:318 E PORT AU PRINCE LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-3667
Practice Address - Country:US
Practice Address - Phone:602-368-7005
Practice Address - Fax:602-368-7005
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL10677101YA0400X
IL071-005677103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)