Provider Demographics
NPI:1891118055
Name:D'VINE THERAPEUTIC SERVICES, INC.
Entity Type:Organization
Organization Name:D'VINE THERAPEUTIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:YOLLE-GUIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DERVIL
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:954-682-7903
Mailing Address - Street 1:3900 W COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 232
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3328
Mailing Address - Country:US
Mailing Address - Phone:954-682-7903
Mailing Address - Fax:786-497-3863
Practice Address - Street 1:3900 W COMMERCIAL BLVD
Practice Address - Street 2:SUITE 232
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33309-3328
Practice Address - Country:US
Practice Address - Phone:954-682-7903
Practice Address - Fax:786-497-3863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 2648106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty