Provider Demographics
NPI:1598189722
Name:DIVINE, KATRINA MARIE
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:MARIE
Last Name:DIVINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:
Other - Last Name:VISGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15393 SHADE RD
Mailing Address - Street 2:
Mailing Address - City:GUYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45735-7503
Mailing Address - Country:US
Mailing Address - Phone:530-205-8302
Mailing Address - Fax:
Practice Address - Street 1:15393 SHADE RD
Practice Address - Street 2:
Practice Address - City:GUYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45735-7503
Practice Address - Country:US
Practice Address - Phone:530-205-8302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor