Provider Demographics
NPI:1659076123
Name:DIVINE MENTAL HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:DIVINE MENTAL HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHIKAODI
Authorized Official - Middle Name:C
Authorized Official - Last Name:IBEKU
Authorized Official - Suffix:
Authorized Official - Credentials:DNP & FNP
Authorized Official - Phone:973-223-8417
Mailing Address - Street 1:940 STUYVESANT AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-6995
Mailing Address - Country:US
Mailing Address - Phone:973-223-8417
Mailing Address - Fax:908-686-9445
Practice Address - Street 1:940 STUYVESANT AVE FL 2
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-6995
Practice Address - Country:US
Practice Address - Phone:973-223-8417
Practice Address - Fax:908-686-9445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty