Provider Demographics
NPI:1780061283
Name:DIVERS, CAITLIN KELSEY (ATC)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:KELSEY
Last Name:DIVERS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 E CLINTON ST
Mailing Address - Street 2:#2136
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5802
Mailing Address - Country:US
Mailing Address - Phone:419-577-2225
Mailing Address - Fax:
Practice Address - Street 1:888 E CLINTON ST
Practice Address - Street 2:#2136
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5802
Practice Address - Country:US
Practice Address - Phone:419-577-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer