Provider Demographics
NPI:1811375017
Name:DIVINE WORKS
Entity Type:Organization
Organization Name:DIVINE WORKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-779-4493
Mailing Address - Street 1:5735 E HASTINGS ARCH
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1506
Mailing Address - Country:US
Mailing Address - Phone:757-779-4493
Mailing Address - Fax:
Practice Address - Street 1:4100 VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1744
Practice Address - Country:US
Practice Address - Phone:757-779-4493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102368101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty