Provider Demographics
NPI:1245766690
Name:DEVINE INTERVENTIONS GROUP, LLC
Entity Type:Organization
Organization Name:DEVINE INTERVENTIONS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:267-200-0284
Mailing Address - Street 1:5245 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3711
Mailing Address - Country:US
Mailing Address - Phone:267-428-0031
Mailing Address - Fax:267-200-0284
Practice Address - Street 1:5245 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3711
Practice Address - Country:US
Practice Address - Phone:267-428-0031
Practice Address - Fax:267-200-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007555101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPC007555OtherLICENCE