Provider Demographics
NPI:1013155027
Name:DIVELY, DANIELLE L (PSY D)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:L
Last Name:DIVELY
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:LEIGHTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSY D
Mailing Address - Street 1:7564 WOODBURY PIKE (PO BOX 155)
Mailing Address - Street 2:
Mailing Address - City:ROARING SPRING
Mailing Address - State:PA
Mailing Address - Zip Code:16673
Mailing Address - Country:US
Mailing Address - Phone:814-729-7316
Mailing Address - Fax:814-729-7538
Practice Address - Street 1:7564 WOODBURY PIKE
Practice Address - Street 2:
Practice Address - City:ROARING SPRING
Practice Address - State:PA
Practice Address - Zip Code:16673
Practice Address - Country:US
Practice Address - Phone:814-729-7316
Practice Address - Fax:814-729-7538
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016634103T00000X, 103TC0700X
PAPS016634PA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000000285381OtherUNISON
PA1023128880004Medicaid
PA1023128880003Medicaid
PA164856RGDOtherMEDICARE
PA002106964OtherHIGHMARK BLUE CROSS BLUE SHIELD
PA1007708200003Medicaid
PA102312888Medicaid
PA1023128880002Medicaid