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General NPI Number Information
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NPI Number | 1376255752
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Entity Type | Organization
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Legal Business Name | DIVINA FAMILY COUNSELING SERVICES
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Dates
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Enumeration Date | 12/19/2022
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Last Update Date | 10/31/2023
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Provider Practice Location Address
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Address Line | 325 W HOSPITALITY LN STE 110
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City | SAN BERNARDINO
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State | CA
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Zip | 92408-3210
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Country | US
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Telephone | 909-375-3816
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Fax |
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Provider Business Mailing Address
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Address Line | 325 W HOSPITALITY LN STE 110
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City | SAN BERNARDINO
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State | CA
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Zip | 92408-3210
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Country | US
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Telephone | 909-375-3816
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Fax |
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Authorized Official
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Title or Position | CLINICAL THERAPIST
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Name | LORI AYALA
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Credential | LPCC
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Telephone | 909-375-3816
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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