Provider Demographics
NPI:1356219661
Name:NEURODIVERGENT SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:NEURODIVERGENT SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COTA
Authorized Official - Prefix:
Authorized Official - First Name:CANAAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:COTA, MD
Authorized Official - Phone:571-389-4447
Mailing Address - Street 1:3145 QUEENSBERRY DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-2305
Mailing Address - Country:US
Mailing Address - Phone:571-389-4447
Mailing Address - Fax:
Practice Address - Street 1:3145 QUEENSBERRY DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTOWN
Practice Address - State:MD
Practice Address - Zip Code:20639-2305
Practice Address - Country:US
Practice Address - Phone:571-389-4447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-28
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty