Provider Demographics
NPI:1033611181
Name:DIVINE, MICHAEL RYAN (BCBA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RYAN
Last Name:DIVINE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:RYAN
Other - Last Name:OLDFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:3441 FORT CAMPBELL BLVD STE F3
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-6684
Mailing Address - Country:US
Mailing Address - Phone:931-449-0063
Mailing Address - Fax:
Practice Address - Street 1:3441 FORT CAMPBELL BLVD STE F3
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-6684
Practice Address - Country:US
Practice Address - Phone:931-449-0063
Practice Address - Fax:931-896-2737
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-16-17545106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNRBT-16-17545OtherBACB
1-19-38668OtherBEHAVIOR ANALYST CERTIFICATION BOARD (BACB)