MEDICARE: DIVINE HEALTH PSYCHOTHERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1609736933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HEALTH PSYCHOTHERAPY LLC

Provider Business Mailing Address
First Line	:	11728 205TH ST UNIT 3
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90715-3401
Country	:	US
Telephone Number	:	323-571-7855
Fax Number	:

Provider Business Practice Location Address
First Line	:	3780 KILROY AIRPORT WAY STE 200
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-2458
Country	:	US
Telephone Number	:	323-571-7855
Fax Number	:

Authorized Official
Title or Position	:	DNP
Name	:	FUTURE OGBEBOR
Credential	:
Telephone Number	:	323-571-7855

Provider Enumeration Date	:	11/18/2025
Last Update Date	:	01/05/2026

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