MEDICARE: DIVASILE ENTERPRISES, INC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	MH10875	FL

General Provider Information

NPI Number	:	1952720443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVASILE ENTERPRISES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 285
Second Line	:
City	:	DUNEDIN
State	:	FL
Zip	:	34697-0285
Country	:	US
Telephone Number	:	727-278-5757
Fax Number	:	866-266-6555

Provider Business Practice Location Address
First Line	:	6710 EMBASSY BLVD
Second Line	:	SUITE 202
City	:	PORT RICHEY
State	:	FL
Zip	:	34668-7754
Country	:	US
Telephone Number	:	727-278-5757
Fax Number	:	866-266-6555

Authorized Official
Title or Position	:	CEO
Name	:	MS. MARIE ELISA DILLINGER-VASILE
Credential	:	LMHC
Telephone Number	:	727-278-5757

Provider Enumeration Date	:	04/11/2014
Last Update Date	:	04/11/2014

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