Provider Demographics
NPI:1205616679
Name:DIVINE MENTAL HEALTHCARE SERVICES LLC
Entity type:Organization
Organization Name:DIVINE MENTAL HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:STUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:915-820-0315
Mailing Address - Street 1:1504 PETAYA LN
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-8497
Mailing Address - Country:US
Mailing Address - Phone:915-820-0315
Mailing Address - Fax:
Practice Address - Street 1:1900 N MESA ST STE C
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3309
Practice Address - Country:US
Practice Address - Phone:915-820-0315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-03
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty