Provider Demographics
NPI:1942005830
Name:DIVERGENT SHADES
Entity type:Organization
Organization Name:DIVERGENT SHADES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OWNER/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:LEUFROY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:818-369-9060
Mailing Address - Street 1:625 FAIR OAKS AVE STE 358
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5812
Mailing Address - Country:US
Mailing Address - Phone:626-460-6012
Mailing Address - Fax:
Practice Address - Street 1:625 FAIR OAKS AVE STE 358
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-5812
Practice Address - Country:US
Practice Address - Phone:626-460-6012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-15
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1891120085OtherTARA LEUFROY NPI
1467877134OtherSTEPHANIE REITER MORRISSEY'S NPI