Healthcare Provider Details

I. General information

NPI: 1336060391
Provider Name (Legal Business Name): DIVINE INTERVENTIONIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 TODD ST
CHARLOTTE TN
37036-4909
US

IV. Provider business mailing address

123 TODD ST
CHARLOTTE TN
37036-4909
US

V. Phone/Fax

Practice location:
  • Phone: 615-218-4571
  • Fax:
Mailing address:
  • Phone: 615-218-4571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RONCEY DECOY EDMONDSON
Title or Position: CEO- NON-LICENSED OWNER
Credential: CPRS
Phone: 615-218-4571