Provider Demographics
NPI:1578291308
Name:DIVINE WELLNESS THERAPEUTIC CENTER PLLC
Entity Type:Organization
Organization Name:DIVINE WELLNESS THERAPEUTIC CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MIRASSOU
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:910-670-7340
Mailing Address - Street 1:3077 N MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-1735
Mailing Address - Country:US
Mailing Address - Phone:910-275-5766
Mailing Address - Fax:866-990-0668
Practice Address - Street 1:3077 N MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-1735
Practice Address - Country:US
Practice Address - Phone:910-275-5766
Practice Address - Fax:866-990-0668
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?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health