Healthcare Provider Details

I. General information

NPI: 1346979093
Provider Name (Legal Business Name): A DIVINE TIME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8539 MONROE RD # 123
CHARLOTTE NC
28212-7510
US

IV. Provider business mailing address

8539 MONROE RD STE 123
CHARLOTTE NC
28212-7510
US

V. Phone/Fax

Practice location:
  • Phone: 336-541-3485
  • Fax:
Mailing address:
  • Phone: 704-707-3799
  • Fax: 704-817-9585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRESSA CORBETT
Title or Position: ADMINISTRATOR
Credential: LCSW
Phone: 336-541-3485