Provider Demographics
NPI:1366693483
Name:GOSSETT-DIVINE, CLAUDIA LILIAN (LPC/MHSP,LADAC)
Entity Type:Individual
Prefix:MS
First Name:CLAUDIA
Middle Name:LILIAN
Last Name:GOSSETT-DIVINE
Suffix:
Gender:F
Credentials:LPC/MHSP,LADAC
Other - Prefix:MS
Other - First Name:CLAUDIA
Other - Middle Name:
Other - Last Name:GOSSETT-DIVINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC,LADAC
Mailing Address - Street 1:550 HARTS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-9538
Mailing Address - Country:US
Mailing Address - Phone:731-424-4385
Mailing Address - Fax:731-424-4385
Practice Address - Street 1:25 SECURITY DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3754
Practice Address - Country:US
Practice Address - Phone:731-668-1271
Practice Address - Fax:731-424-4385
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000175101YA0400X
TN0000001758101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)