=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568613545
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. TAMBRA K DIVINE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2008
-----------------------------------------------------
Last Update Date | 05/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 BATES AVE
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94520-1376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-326-0479
-----------------------------------------------------
Fax | 925-608-5188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2358 FIELDGATE DR
-----------------------------------------------------
City | PITTSBURG
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94565-7360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-768-0785
-----------------------------------------------------
Fax | 925-608-5188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------