MEDICARE: CORY S DIVINE CSAC, LPC

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	101YP2500X	Professional Counselor	6901-125	WI
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	15367-132	WI

General Provider Information

NPI Number	:	1558494211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORY S DIVINE CSAC, LPC

Provider Business Mailing Address
First Line	:	6402 ODANA RD STE 106
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53719-1123
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6402 ODANA RD STE 106
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53719-1123
Country	:	US
Telephone Number	:	608-220-8627
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	01/02/2025

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