Provider Demographics
NPI:1083013023
Name:DIVINE INTERVENTION SPEECH-LANGUAGE THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:DIVINE INTERVENTION SPEECH-LANGUAGE THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-560-1135
Mailing Address - Street 1:PO BOX 431
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:GA
Mailing Address - Zip Code:31635-0431
Mailing Address - Country:US
Mailing Address - Phone:229-560-1135
Mailing Address - Fax:229-455-2099
Practice Address - Street 1:108 S HIGHWAY 135
Practice Address - Street 2:SUITE A
Practice Address - City:LAKELAND
Practice Address - State:GA
Practice Address - Zip Code:31635-6356
Practice Address - Country:US
Practice Address - Phone:229-560-1135
Practice Address - Fax:229-455-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty