Provider Demographics
NPI:1235431784
Name:DIVINE INTERVENTION COUNSELING SERVICES
Entity Type:Organization
Organization Name:DIVINE INTERVENTION COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:EKONG
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:843-642-1492
Mailing Address - Street 1:3236 LANDMARK DRIVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418
Mailing Address - Country:US
Mailing Address - Phone:843-642-1492
Mailing Address - Fax:843-225-9124
Practice Address - Street 1:3236 LANDMARK DRIVE
Practice Address - Street 2:SUITE 124
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418
Practice Address - Country:US
Practice Address - Phone:843-642-1492
Practice Address - Fax:843-225-9124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5026251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1071Medicaid