Basic Information
| Provider Information | |||||||||
| NPI: | 1649720020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | KRYSTIN | ||||||||
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| Credential: | M.S., NCC, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 DOCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178428910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708372123 | ||||||||
| FaxNumber: | 5708372185 | ||||||||
| Practice Location | |||||||||
| Address1: | 270 SUSQUEHANNA VALLEY MALL DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178709115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707684441 | ||||||||
| FaxNumber: | 5707684195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2016 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PC009196 | PA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | PC009196 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.