Healthcare Provider Details

I. General information

NPI: 1376255752
Provider Name (Legal Business Name): DIVINA FAMILY COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W HOSPITALITY LN STE 110
SAN BERNARDINO CA
92408-3210
US

IV. Provider business mailing address

325 W HOSPITALITY LN STE 110
SAN BERNARDINO CA
92408-3210
US

V. Phone/Fax

Practice location:
  • Phone: 909-375-3816
  • Fax:
Mailing address:
  • Phone: 909-375-3816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: LORI AYALA
Title or Position: CLINICAL THERAPIST
Credential: LPCC
Phone: 909-375-3816