Healthcare Provider Details

I. General information

NPI: 1336945443
Provider Name (Legal Business Name): DIVINE WELLNESS AND PSYCHIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 SECURITY BLVD STE 100
GWYNN OAK MD
21207-5284
US

IV. Provider business mailing address

9220 SEWALL AVE
LAUREL MD
20723-1889
US

V. Phone/Fax

Practice location:
  • Phone: 301-665-0074
  • Fax: 301-637-1706
Mailing address:
  • Phone: 301-665-0074
  • Fax: 301-637-1706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OLADOYIN OLADAYO ADEKOLA
Title or Position: PRESIDENT
Credential:
Phone: 301-665-0662