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General NPI Number Information
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NPI Number | 1144540535
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Entity Type | Individual
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Provider Name | GLENDORA DVINE LPC
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Gender | Female
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Dates
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Enumeration Date | 06/08/2010
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Last Update Date | 01/31/2024
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Provider Practice Location Address
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Address Line | 141 BRIDGEMILL DR
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City | HAMPTON
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State | GA
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Zip | 30228-5536
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Country | US
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Telephone | 782-125-1466
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Fax | 788-313-5546
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Provider Business Mailing Address
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Address Line | 922 HIGHWAY 81 E STE 348
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City | MCDONOUGH
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State | GA
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Zip | 30252-2978
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Country | US
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Telephone | 678-212-5146
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Fax | 678-831-3554
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 006210
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License Number State | GA
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