Provider Demographics
NPI:1144540535
Name:DVINE, GLENDORA (LPC)
Entity type:Individual
Prefix:MRS
First Name:GLENDORA
Middle Name:
Last Name:DVINE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 HIGHWAY 81 E STE 348
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-2978
Mailing Address - Country:US
Mailing Address - Phone:678-212-5146
Mailing Address - Fax:678-831-3554
Practice Address - Street 1:141 BRIDGEMILL DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-5536
Practice Address - Country:US
Practice Address - Phone:782-125-1466
Practice Address - Fax:788-313-5546
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006210101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional