Provider Demographics
NPI:1407584204
Name:DIVINE MIND THERAPEUTICS LLC
Entity Type:Organization
Organization Name:DIVINE MIND THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-LCPC-MFT
Authorized Official - Phone:202-766-4216
Mailing Address - Street 1:2901 CONNECTICUT AVE NW APT B2
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-1451
Mailing Address - Country:US
Mailing Address - Phone:202-766-4216
Mailing Address - Fax:
Practice Address - Street 1:1806 SUMMIT AVE SET 300 PMB 2034
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230
Practice Address - Country:US
Practice Address - Phone:571-249-2519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty