Basic Information
| Provider Information | |||||||||
| NPI: | 1760766208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 166 CHRISTINA MARIE DR | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633687872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144439228 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2187 SWANSON AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864036838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288553432 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2011 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2008006146 | MO | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 2018025246 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 229481 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 498748 | 05 | AZ | MEDICAID |