Healthcare Provider Details

I. General information

NPI: 1003320888
Provider Name (Legal Business Name): DIVINE PSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 SHALLOWFORD RD STE G3
MARIETTA GA
30062-5021
US

IV. Provider business mailing address

2960 SILVERPLUME DR
FORT COLLINS CO
80526-2488
US

V. Phone/Fax

Practice location:
  • Phone: 678-626-7207
  • Fax:
Mailing address:
  • Phone: 678-626-7207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY003469
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY003469
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPSY003469
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY003469
License Number StateGA

VIII. Authorized Official

Name: DR. SARA VELEZ
Title or Position: CLINICAL PSYCHOLOGIST & OWNER
Credential: PSYD
Phone: 678-626-7207