MEDICARE: DIVINE PURPOSE COUNSELING CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1083354666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE PURPOSE COUNSELING CENTER LLC

Provider Business Mailing Address
First Line	:	6024 S PRINCETON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60621-3316
Country	:	US
Telephone Number	:	773-633-8695
Fax Number	:

Provider Business Practice Location Address
First Line	:	6024 S PRINCETON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60621-3316
Country	:	US
Telephone Number	:	773-633-8695
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PROFESSIONAL COUNSELOR
Name	:	EVELYNANN DAVIS
Credential	:	LCPC
Telephone Number	:	773-633-8695

Provider Enumeration Date	:	03/31/2022
Last Update Date	:	03/31/2022

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