Healthcare Provider Details

I. General information

NPI: 1356891246
Provider Name (Legal Business Name): MRS. PAMELLA B DIVINITY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELLA B DIVINITY M.ED., PLPC, NCC

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 GENERAL PERSHING ST
MANDEVILLE LA
70448-5125
US

IV. Provider business mailing address

PO BOX 1385 12434 HOLLINS ROAD
FOLSOM LA
70437-1385
US

V. Phone/Fax

Practice location:
  • Phone: 985-465-4250
  • Fax:
Mailing address:
  • Phone: 985-237-4930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6656
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number6656
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: