Provider Demographics
NPI:1245930411
Name:DIVINE, KIMBERLY (LPC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:DIVINE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10408 W 70TH TER APT 201
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66203-4267
Mailing Address - Country:US
Mailing Address - Phone:620-794-3619
Mailing Address - Fax:
Practice Address - Street 1:21901 S VICTORY RD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:KS
Practice Address - Zip Code:66083-9660
Practice Address - Country:US
Practice Address - Phone:913-357-5381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04264101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor