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General NPI Number Information
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NPI Number | 1669997599
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Entity Type | Organization
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Legal Business Name | DIVINE THERAPY, LLC
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Dates
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Enumeration Date | 08/11/2017
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Last Update Date | 01/01/2025
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Provider Practice Location Address
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Address Line | 209 ROYA LN STE 4
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City | BRYANT
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State | AR
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Zip | 72022-2669
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Country | US
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Telephone | 501-213-1077
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Fax |
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Provider Business Mailing Address
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Address Line | 209 ROYA LN STE 4
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City | BRYANT
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State | AR
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Zip | 72022-2669
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Country | US
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Telephone | 501-213-1077
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | JULIE FANT CHILDERS
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Credential | LCSW
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Telephone | 501-213-1077
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C1416
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License Number State | AR
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