Provider Demographics
NPI:1497524250
Name:DIVINITY'S RESIDENTIAL SERVICE
Entity Type:Organization
Organization Name:DIVINITY'S RESIDENTIAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMI
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-639-8258
Mailing Address - Street 1:2814 VIENNA VIEW CT SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44706-5629
Mailing Address - Country:US
Mailing Address - Phone:330-639-8258
Mailing Address - Fax:
Practice Address - Street 1:2814 VIENNA VIEW CT SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44706-5629
Practice Address - Country:US
Practice Address - Phone:330-639-8258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency