Provider Demographics
NPI:1356891246
Name:DIVINITY, PAMELLA B
Entity type:Individual
Prefix:MRS
First Name:PAMELLA
Middle Name:B
Last Name:DIVINITY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:PAMELLA
Other - Middle Name:B
Other - Last Name:DIVINITY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, PLPC, NCC
Mailing Address - Street 1:PO BOX 1385
Mailing Address - Street 2:12434 HOLLINS ROAD
Mailing Address - City:FOLSOM
Mailing Address - State:LA
Mailing Address - Zip Code:70437-1385
Mailing Address - Country:US
Mailing Address - Phone:985-237-4930
Mailing Address - Fax:
Practice Address - Street 1:2150 GENERAL PERSHING ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-5125
Practice Address - Country:US
Practice Address - Phone:985-465-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6656171M00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional