Provider Demographics
NPI:1447930706
Name:DIVINE HEALTH PSYCHIATRIC SERVICES LLC
Entity type:Organization
Organization Name:DIVINE HEALTH PSYCHIATRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GBALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-204-3919
Mailing Address - Street 1:117 E CHERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3023
Mailing Address - Country:US
Mailing Address - Phone:443-204-3919
Mailing Address - Fax:410-521-3671
Practice Address - Street 1:117 E CHERRY HILL RD
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-3023
Practice Address - Country:US
Practice Address - Phone:443-204-3919
Practice Address - Fax:410-521-3671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty