Provider Demographics
NPI:1396065793
Name:DVINE SYSTEMS GA LLC
Entity type:Organization
Organization Name:DVINE SYSTEMS GA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDORA
Authorized Official - Middle Name:
Authorized Official - Last Name:DVINE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-212-5146
Mailing Address - Street 1:255 RACETRACK RD
Mailing Address - Street 2:#26
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-6834
Mailing Address - Country:US
Mailing Address - Phone:678-212-5146
Mailing Address - Fax:678-831-3554
Practice Address - Street 1:255 RACETRACK RD
Practice Address - Street 2:26
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-6834
Practice Address - Country:US
Practice Address - Phone:678-212-5146
Practice Address - Fax:678-831-3554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006210101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty