Healthcare Provider Details

I. General information

NPI: 1609736933
Provider Name (Legal Business Name): DIVINE HEALTH PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 KILROY AIRPORT WAY STE 200
LONG BEACH CA
90806-2458
US

IV. Provider business mailing address

11728 205TH ST UNIT 3
LAKEWOOD CA
90715-3401
US

V. Phone/Fax

Practice location:
  • Phone: 323-571-7855
  • Fax:
Mailing address:
  • Phone: 323-571-7855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: FUTURE OGBEBOR
Title or Position: DNP
Credential:
Phone: 323-571-7855