Provider Demographics
NPI:1306373170
Name:DIVINE PSYCHIATRIC CARE, LLC
Entity Type:Organization
Organization Name:DIVINE PSYCHIATRIC CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARSTARPHEN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:251-402-0450
Mailing Address - Street 1:2651 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-1325
Mailing Address - Country:US
Mailing Address - Phone:251-402-0450
Mailing Address - Fax:
Practice Address - Street 1:2651 CEDAR DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-1325
Practice Address - Country:US
Practice Address - Phone:251-402-0450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN165081363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty