Provider Demographics
NPI:1780987503
Name:DIVERSE LEGACY INCORPORATED
Entity type:Organization
Organization Name:DIVERSE LEGACY INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:708-223-8405
Mailing Address - Street 1:1717 N NAPER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8802
Mailing Address - Country:US
Mailing Address - Phone:708-223-8405
Mailing Address - Fax:
Practice Address - Street 1:1717 N NAPER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8802
Practice Address - Country:US
Practice Address - Phone:708-223-8405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-007847103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3611Medicare UPIN