Healthcare Provider Details

I. General information

NPI: 1124836978
Provider Name (Legal Business Name): DIVINITY ABA, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2024
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 EMERALD KNOLL DRIVE
KELLER TX
76248-1506
US

IV. Provider business mailing address

1508 EMERALD KNOLL DRIVE
KELLER TX
76248-1506
US

V. Phone/Fax

Practice location:
  • Phone: 817-455-5920
  • Fax:
Mailing address:
  • Phone: 817-455-5920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. BETH A WORMAN
Title or Position: OWNER, CEO
Credential:
Phone: 817-455-5920