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General NPI Number Information
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NPI Number | 1083013023
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Entity Type | Organization
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Legal Business Name | DIVINE INTERVENTION SPEECH-LANGUAGE THERAPY SERVICES, LLC
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Dates
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Enumeration Date | 08/15/2014
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Last Update Date | 08/15/2014
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Provider Practice Location Address
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Address Line | 108 S HIGHWAY 135 SUITE A
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City | LAKELAND
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State | GA
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Zip | 31635-6356
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Country | US
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Telephone | 229-560-1135
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Fax | 229-455-2099
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Provider Business Mailing Address
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Address Line | PO BOX 431
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City | LAKELAND
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State | GA
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Zip | 31635-0431
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Country | US
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Telephone | 229-560-1135
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Fax | 229-455-2099
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Authorized Official
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Title or Position | OWNER
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Name | KEISHA BANKS
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Credential |
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Telephone | 229-560-1135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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