Healthcare Provider Details

I. General information

NPI: 1811454218
Provider Name (Legal Business Name): THE PUPPY WATER ENTERTAINMENT FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 DEEP VALLEY DR # 200057
ROLLING HILLS ESTATES CA
90274-3629
US

IV. Provider business mailing address

952 SCHOOL ST STE 185
NAPA CA
94559-2826
US

V. Phone/Fax

Practice location:
  • Phone: 424-279-3898
  • Fax: 916-407-3010
Mailing address:
  • Phone: 424-279-3898
  • Fax: 916-407-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL

VIII. Authorized Official

Name: PRINCESS OMO OKIEME
Title or Position: PRESIDENT
Credential: LCSW
Phone: 424-279-3898