Basic Information
| Provider Information | |||||||||
| NPI: | 1003320888 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIVINE PSYCHOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 SILVERPLUME DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805262488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786267207 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4343 SHALLOWFORD RD STE G3 | ||||||||
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| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300625021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786267207 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2017 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | VELEZ | ||||||||
| AuthorizedOfficialFirstName: | SARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST & OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6786267207 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | PSY003469 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TH0004X | PSY003469 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Health | 103TR0400X | PSY003469 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation | 103TC0700X | PSY003469 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.