Provider Demographics
NPI:1578706198
Name:DIVINE, DANA LYN (MED)
Entity Type:Individual
Prefix:MS
First Name:DANA
Middle Name:LYN
Last Name:DIVINE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2232 INDIANA AVE
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-2139
Mailing Address - Country:US
Mailing Address - Phone:806-793-6160
Mailing Address - Fax:806-799-0825
Practice Address - Street 1:2232 INDIANA AVE
Practice Address - Street 2:SUITE ONE
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-2139
Practice Address - Country:US
Practice Address - Phone:806-793-6160
Practice Address - Fax:806-799-0825
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17300101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional