Provider Demographics
NPI:1750649554
Name:TICHA, DIVINE F
Entity Type:Individual
Prefix:MR
First Name:DIVINE
Middle Name:F
Last Name:TICHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13994 BALTIMORE AVENUE
Mailing Address - Street 2:13994 BALTIMORE AVENUE SUITE 102
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707
Mailing Address - Country:US
Mailing Address - Phone:240-491-2868
Mailing Address - Fax:301-477-1758
Practice Address - Street 1:1818 NEW YORK AVE NE
Practice Address - Street 2:117 GLOBAL HEALTHCARE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002
Practice Address - Country:US
Practice Address - Phone:202-480-0813
Practice Address - Fax:202-503-2363
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR197963363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health