Provider Demographics
NPI:1174588230
Name:DIVINEY, CHARLES L III (MC, LPC, NCC, CCMHC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:L
Last Name:DIVINEY
Suffix:III
Gender:M
Credentials:MC, LPC, NCC, CCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3872
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3872
Mailing Address - Country:US
Mailing Address - Phone:801-201-4096
Mailing Address - Fax:801-521-4227
Practice Address - Street 1:352 DENVER ST
Practice Address - Street 2:SUITE 215
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3000
Practice Address - Country:US
Practice Address - Phone:801-521-4227
Practice Address - Fax:801-359-0777
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT340426-6004101YP2500X, 101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT34042660001001OtherBCBS