Provider Demographics
NPI:1386155968
Name:DIVINE TOUCH THERAPEUTIC COUNSELING AND MENTORING SERVICES , LLC
Entity type:Organization
Organization Name:DIVINE TOUCH THERAPEUTIC COUNSELING AND MENTORING SERVICES , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BOLADALE
Authorized Official - Middle Name:WURAOLA
Authorized Official - Last Name:ADEGOROYE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:240-481-9962
Mailing Address - Street 1:107 MOUNTAIN RD STE D
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-7159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 MOUNTAIN RD STE D
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-7159
Practice Address - Country:US
Practice Address - Phone:240-481-9962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1155938Medicaid