Provider Demographics
NPI:1497228431
Name:DIVINE, HERLAY (LCSW)
Entity Type:Individual
Prefix:
First Name:HERLAY
Middle Name:
Last Name:DIVINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 N TURNER AVE UNIT 1012
Mailing Address - Street 2:
Mailing Address - City:GUASTI
Mailing Address - State:CA
Mailing Address - Zip Code:91743-1603
Mailing Address - Country:US
Mailing Address - Phone:201-456-4595
Mailing Address - Fax:
Practice Address - Street 1:323 N TURNER AVE UNIT 1012
Practice Address - Street 2:
Practice Address - City:GUASTI
Practice Address - State:CA
Practice Address - Zip Code:91743-1603
Practice Address - Country:US
Practice Address - Phone:201-456-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121710101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health