Healthcare Provider Details

I. General information

NPI: 1639643323
Provider Name (Legal Business Name): PRINCESS OMO OKIEME
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 DEEP VALLEY DR # 200-057
ROLLING HILLS ESTATES CA
90274-3629
US

IV. Provider business mailing address

3350 E 7TH ST # 338
LONG BEACH CA
90804-5003
US

V. Phone/Fax

Practice location:
  • Phone: 424-279-3898
  • Fax:
Mailing address:
  • Phone: 424-279-3898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW112661
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW112661
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: