Provider Demographics
| NPI: | 1437912532 |
|---|---|
| Name: | DIVINE CARE SOURCE INC |
| Entity Type: | Organization |
| Organization Name: | DIVINE CARE SOURCE INC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | CRYSTAL |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | ROBERSON |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MSW |
| Authorized Official - Phone: | 478-305-3019 |
| Mailing Address - Street 1: | 31055 PARROT REEF CT |
| Mailing Address - Street 2: | |
| Mailing Address - City: | WESLEY CHAPEL |
| Mailing Address - State: | FL |
| Mailing Address - Zip Code: | 33545-5149 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 478-305-3019 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 31055 PARROT REEF CT |
| Practice Address - Street 2: | |
| Practice Address - City: | WESLEY CHAPEL |
| Practice Address - State: | FL |
| Practice Address - Zip Code: | 33545-5149 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 478-305-3019 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2024-02-01 |
| Last Update Date: | 2024-02-01 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 251E00000X | Agencies | Home Health | ||
| No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | Group - Multi-Specialty | |
| No | 251B00000X | Agencies | Case Management | ||
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | ||
| No | 253Z00000X | Agencies | In Home Supportive Care | ||
| No | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | ||
| No | 3104A0625X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness | |
| No | 3104A0630X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Behavioral Disturbances | |
| No | 311ZA0620X | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home | |
| No | 322D00000X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | ||
| No | 385H00000X | Respite Care Facility | Respite Care | ||
| No | 385HR2055X | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | |
| No | 385HR2060X | Respite Care Facility | Respite Care | Respite Care, Intellectual and/or Developmental Disabilities, Child | |
| No | 385HR2065X | Respite Care Facility | Respite Care | Respite Care, Physical Disabilities, Child |
