Healthcare Provider Details

I. General information

NPI: 1578706198
Provider Name (Legal Business Name): DANA LYN DIVINE M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 INDIANA AVE SUITE ONE
LUBBOCK TX
79410-2139
US

IV. Provider business mailing address

2232 INDIANA AVE SUITE ONE
LUBBOCK TX
79410-2139
US

V. Phone/Fax

Practice location:
  • Phone: 806-793-6160
  • Fax: 806-799-0825
Mailing address:
  • Phone: 806-793-6160
  • Fax: 806-799-0825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number17300
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: