Healthcare Provider Details

I. General information

NPI: 1730040197
Provider Name (Legal Business Name): DIVINE HAVEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19825 N COVE RD # 1010
CORNELIUS NC
28031-6446
US

IV. Provider business mailing address

19825 N COVE RD # 1010
CORNELIUS NC
28031-6446
US

V. Phone/Fax

Practice location:
  • Phone: 704-565-9257
  • Fax:
Mailing address:
  • Phone: 704-565-9257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MONIQUE WILLIAMS
Title or Position: OWNER/CEO
Credential:
Phone: 727-506-0177