Provider Demographics
NPI:1790583557
Name:DIVERGENT MINDS MENTAL HEALTH PLLC
Entity type:Organization
Organization Name:DIVERGENT MINDS MENTAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELODEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-301-0133
Mailing Address - Street 1:5445 MARK DABLING BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3850
Mailing Address - Country:US
Mailing Address - Phone:719-301-0133
Mailing Address - Fax:
Practice Address - Street 1:5445 MARK DABLING BLVD STE 105
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3850
Practice Address - Country:US
Practice Address - Phone:719-301-0133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty