1679491823 NPI number — DIVINE DESIGN PSYCHOTHERAPY PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679491823 NPI number — DIVINE DESIGN PSYCHOTHERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVINE DESIGN PSYCHOTHERAPY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679491823
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1735 S KENSINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901-8095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-545-6701
Provider Business Mailing Address Fax Number:
510-370-4034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1735 S KENSINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901-8095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-545-6701
Provider Business Practice Location Address Fax Number:
510-370-4034
Provider Enumeration Date:
07/07/2026

Additional Information

Authorized Official

Authorized Official Last Name:
CARAVELLO
Authorized Official First Name:
ROBYN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
815-545-6701

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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