Healthcare Provider Details

I. General information

NPI: 1235447772
Provider Name (Legal Business Name): CHARLES L DIVINEY III MC LPC NCC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2010
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 S DENVER ST STE 350
SLC UT
84111-3059
US

IV. Provider business mailing address

PO BOX 3872
SLC UT
84110-3872
US

V. Phone/Fax

Practice location:
  • Phone: 801-521-4227
  • Fax: 801-359-0777
Mailing address:
  • Phone: 801-521-4227
  • Fax: 801-359-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number210158-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number340426-6004
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5170621-6004
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6281940-3501
License Number StateUT

VIII. Authorized Official

Name: DEBRA MORRILL
Title or Position: BILLING MANAGER
Credential:
Phone: 801-916-1645