Healthcare Provider Details

I. General information

NPI: 1407599764
Provider Name (Legal Business Name): DIVINE LIFE PSYCHOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 04/15/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11325 PARK SQUARE DR APT K102
BAKERSFIELD CA
93311-8868
US

IV. Provider business mailing address

11325 PARK SQUARE DR APT K102
BAKERSFIELD CA
93311-8868
US

V. Phone/Fax

Practice location:
  • Phone: 818-749-3106
  • Fax:
Mailing address:
  • Phone: 818-749-3106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH LANCASTER
Title or Position: OWNER
Credential: PSYD, MFT
Phone: 818-877-4647