MEDICARE: DEVINE INTERVENTIONS GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	PC007555	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PC007555	OTHER	PA	LICENCE

General Provider Information

NPI Number	:	1245766690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVINE INTERVENTIONS GROUP

Provider Business Mailing Address
First Line	:	6757 GREENE STREET
Second Line	:	OFFICES AT SUMMIT PREBYTERIAN, SUITE 200-C
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-3711
Country	:	US
Telephone Number	:	855-410-8120
Fax Number	:	215-874-8897

Provider Business Practice Location Address
First Line	:	6757 GREENE STREET
Second Line	:	OFFICES AT SUMMIT PREBYTERIAN, SUITE 200-C
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-3711
Country	:	US
Telephone Number	:	855-410-8120
Fax Number	:	215-874-8897

Authorized Official
Title or Position	:	LPC
Name	:	MR. GARY JAMES DEVINE
Credential	:	MA
Telephone Number	:	267-428-0321

Provider Enumeration Date	:	05/04/2017
Last Update Date	:	08/27/2024

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