Provider Demographics
NPI:1801409313
Name:DIVINE BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:DIVINE BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:318-347-4994
Mailing Address - Street 1:2803 JONATHAN LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-5531
Mailing Address - Country:US
Mailing Address - Phone:318-347-4994
Mailing Address - Fax:
Practice Address - Street 1:8870 YOUREE DR STE 105
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2512
Practice Address - Country:US
Practice Address - Phone:318-347-4994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty