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General NPI Number Information
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NPI Number | 1720755473
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Entity Type | Organization
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Legal Business Name | DIVINE INTERVENTION BEHAVIORAL SOLUTIONS LLC
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Dates
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Enumeration Date | 08/29/2021
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Last Update Date | 11/29/2021
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Provider Practice Location Address
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Address Line | 3510 ROSWELL RD NW APT F3
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City | ATLANTA
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State | GA
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Zip | 30305-1219
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Country | US
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Telephone | 678-815-5277
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Fax |
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Provider Business Mailing Address
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Address Line | 3510 ROSWELL RD NW APT F3
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City | ATLANTA
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State | GA
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Zip | 30305-1219
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Country | US
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Telephone | 678-815-5277
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. MARVIN TIMOTHY BLUE JR.
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Credential | M.S., BCBA
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Telephone | 678-815-5277
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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