Provider Demographics
NPI:1184173981
Name:DIEVENDORF, JEAN ELYSE
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:ELYSE
Last Name:DIEVENDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:ELYSE
Other - Last Name:GAUTREAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2257 WHITESIDE AVE SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6044
Mailing Address - Country:US
Mailing Address - Phone:321-405-2583
Mailing Address - Fax:
Practice Address - Street 1:6050 BABCOCK ST SE STE 32
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-4205
Practice Address - Country:US
Practice Address - Phone:321-684-8265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW16874101YM0800X, 1041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical