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General NPI Number Information
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NPI Number | 1417634478
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Entity Type | Organization
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Legal Business Name | DIVINE PATHWAYS SUPPORT SERVICES LLC
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Dates
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Enumeration Date | 06/30/2023
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Last Update Date | 06/30/2023
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Provider Practice Location Address
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Address Line | 917 WINDING TRAIL LN
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City | RICHMOND
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State | VA
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Zip | 23223-2289
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Country | US
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Telephone | 804-389-3201
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Fax |
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Provider Business Mailing Address
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Address Line | 917 WINDING TRAIL LN
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City | RICHMOND
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State | VA
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Zip | 23223-2289
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Country | US
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Telephone | 804-389-3201
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHAWANDA CHANTELLE CHEATHAM
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Credential |
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Telephone | 804-389-3201
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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