Provider Demographics
NPI:1912299173
Name:DIVERSE WELLNESS SOLUTIONS INC
Entity Type:Organization
Organization Name:DIVERSE WELLNESS SOLUTIONS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBALL
Authorized Official - Middle Name:JANE-MARIE
Authorized Official - Last Name:SARGENT
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, PMHCNS-BC
Authorized Official - Phone:919-838-0804
Mailing Address - Street 1:7155 SUNSET LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-8638
Mailing Address - Country:US
Mailing Address - Phone:919-838-0804
Mailing Address - Fax:919-838-1219
Practice Address - Street 1:7155 SUNSET LAKE RD
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-8638
Practice Address - Country:US
Practice Address - Phone:919-838-0804
Practice Address - Fax:919-838-1219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0261495-01261QM0850X, 261QM0855X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCMC030788Medicaid
NC6004025Medicaid
NC527619OtherVALUE OPTIONS
NCNC1277A203OtherMEDICARE PTAN
NC10079OtherBCBS
NCS79270Medicare UPIN