Healthcare Provider Details

I. General information

NPI: 1932697422
Provider Name (Legal Business Name): DIVINE INTERACTIONS EQUINE FACILITATED WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 QUARRY LANE
APOLLO PA
15613
US

IV. Provider business mailing address

554 PLEASANT VIEW DR
APOLLO PA
15613-9225
US

V. Phone/Fax

Practice location:
  • Phone: 724-858-7204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberPC009805
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1891206850
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerLICENSED PROFESSIONAL COUNSELOR

VIII. Authorized Official

Name: SHANNA AUGHENBAUGH
Title or Position: SOLE MEMBER
Credential: MA, NCC, LPC, CCTP
Phone: 724-858-7204