Provider Demographics
NPI:1194447300
Name:DIVINE PATHWAYS LLC
Entity type:Organization
Organization Name:DIVINE PATHWAYS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:606-875-0812
Mailing Address - Street 1:263 WIND CHIME DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3821
Mailing Address - Country:US
Mailing Address - Phone:606-875-0812
Mailing Address - Fax:
Practice Address - Street 1:428 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-6155
Practice Address - Country:US
Practice Address - Phone:606-875-0812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health