Provider Demographics
NPI:1235447772
Name:CHARLES L DIVINEY III MC LPC NCC
Entity Type:Organization
Organization Name:CHARLES L DIVINEY III MC LPC NCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:DIVINEY III MC LCMHC NCC, PHD
Authorized Official - Suffix:
Authorized Official - Credentials:MC LCMHC NCC PHD
Authorized Official - Phone:801-521-4227
Mailing Address - Street 1:PO BOX 3872
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3872
Mailing Address - Country:US
Mailing Address - Phone:801-521-4227
Mailing Address - Fax:801-359-0777
Practice Address - Street 1:352 SO DENVER ST.
Practice Address - Street 2:#215
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84110-3872
Practice Address - Country:US
Practice Address - Phone:801-521-4227
Practice Address - Fax:801-359-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT340426-6004101YP2500X
UT5170621-6004101YP2500X
UT6281940-35011041C0700X
UT210158-4405364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT340426600001001OtherBCBS UT