Provider Demographics
NPI:1053902569
Name:DIVINE MENTAL HEALTH TREATMENT
Entity type:Organization
Organization Name:DIVINE MENTAL HEALTH TREATMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYERS
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:845-238-8853
Mailing Address - Street 1:27 CARPENTER AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2401
Mailing Address - Country:US
Mailing Address - Phone:845-238-8853
Mailing Address - Fax:646-619-4083
Practice Address - Street 1:27 CARPENTER AVE STE 7
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2401
Practice Address - Country:US
Practice Address - Phone:452-388-8538
Practice Address - Fax:646-619-4083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-27
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04672304Medicaid