Provider Demographics
NPI:1417634478
Name:DIVINE PATHWAYS SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:DIVINE PATHWAYS SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWANDA
Authorized Official - Middle Name:CHANTELLE
Authorized Official - Last Name:CHEATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-389-3201
Mailing Address - Street 1:917 WINDING TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-2289
Mailing Address - Country:US
Mailing Address - Phone:804-389-3201
Mailing Address - Fax:
Practice Address - Street 1:917 WINDING TRAIL LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-2289
Practice Address - Country:US
Practice Address - Phone:804-389-3201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health