Provider Demographics
NPI:1932697422
Name:DIVINE INTERACTIONS EQUINE FACILITATED WELLNESS, LLC
Entity Type:Organization
Organization Name:DIVINE INTERACTIONS EQUINE FACILITATED WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUGHENBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MA, NCC, LPC, CCTP
Authorized Official - Phone:724-858-7204
Mailing Address - Street 1:554 PLEASANT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:APOLLO
Mailing Address - State:PA
Mailing Address - Zip Code:15613-9225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1719 QUARRY LANE
Practice Address - Street 2:
Practice Address - City:APOLLO
Practice Address - State:PA
Practice Address - Zip Code:15613
Practice Address - Country:US
Practice Address - Phone:724-858-7204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009805261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1891206850OtherLICENSED PROFESSIONAL COUNSELOR