Provider Demographics
NPI:1184338618
Name:DIVINE RESTORATION BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:DIVINE RESTORATION BEHAVIORAL HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PMHNP-BC
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MBOUADEU
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:774-318-7893
Mailing Address - Street 1:98 LOWER WESTFIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-2744
Mailing Address - Country:US
Mailing Address - Phone:774-420-1993
Mailing Address - Fax:
Practice Address - Street 1:98 LOWER WESTFIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2744
Practice Address - Country:US
Practice Address - Phone:774-318-7893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-10
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty