Healthcare Provider Details

I. General information

NPI: 1568613545
Provider Name (Legal Business Name): MRS. TAMBRA K DIVINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 05/06/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 BATES AVE
CONCORD CA
94520-1376
US

IV. Provider business mailing address

2358 FIELDGATE DR
PITTSBURG CA
94565-7360
US

V. Phone/Fax

Practice location:
  • Phone: 925-326-0479
  • Fax: 925-608-5188
Mailing address:
  • Phone: 925-768-0785
  • Fax: 925-608-5188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: