Provider Demographics
NPI:1902558091
Name:THE GREAT DIVINE CENTER LLC
Entity Type:Organization
Organization Name:THE GREAT DIVINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYMALETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:LLPC
Authorized Official - Phone:313-480-4766
Mailing Address - Street 1:17163 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2279
Mailing Address - Country:US
Mailing Address - Phone:313-480-4766
Mailing Address - Fax:
Practice Address - Street 1:17169 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-2279
Practice Address - Country:US
Practice Address - Phone:313-480-4766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty