Provider Demographics
NPI:1043045941
Name:DIVE THERAPY & CONSULTING LLC
Entity type:Organization
Organization Name:DIVE THERAPY & CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SPESHAL
Authorized Official - Middle Name:TW
Authorized Official - Last Name:GAUTIER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-800-1998
Mailing Address - Street 1:1700 NORTHSIDE DR NW STE A7, PMB 1704
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2695
Mailing Address - Country:US
Mailing Address - Phone:404-800-1998
Mailing Address - Fax:404-393-0989
Practice Address - Street 1:1055 HOWELL MILL RD NW FL 8
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-5557
Practice Address - Country:US
Practice Address - Phone:404-800-1998
Practice Address - Fax:404-393-0989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-03
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty