Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor |
NPI | 1154721496 |
---|---|
Provider Name | Dr. Patrick Divietri |
First Address | Manassas, VA 20109-2507 |
Second Address | Manassas, VA 20109-2507 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2014 |
Last Update Date | 22/08/2014 |