Healthcare Provider Details

I. General information

NPI: 1104779750
Provider Name (Legal Business Name): DIVINE DESIGN PSYCHIATRY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 02/16/2026
Certification Date: 02/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 CHESAPEAKE JUNCTION LN
O FALLON IL
62269-7035
US

IV. Provider business mailing address

853 CHESAPEAKE JUNCTION LN
O FALLON IL
62269-7035
US

V. Phone/Fax

Practice location:
  • Phone: 217-816-7928
  • Fax: 616-208-2675
Mailing address:
  • Phone: 217-816-7928
  • Fax: 616-208-2675

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: ANGELA SEVERADO
Title or Position: NURSE PRACTITIONER/OWNER
Credential: FNP/PMHNP
Phone: 217-816-7928