Provider Demographics
NPI:1689456691
Name:DIVINE BEHAVIORAL HEALTH CLINIC PLLC
Entity Type:Organization
Organization Name:DIVINE BEHAVIORAL HEALTH CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IJEOMA
Authorized Official - Middle Name:E
Authorized Official - Last Name:OSUJI
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:817-874-2965
Mailing Address - Street 1:803 MERYTON CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4337
Mailing Address - Country:US
Mailing Address - Phone:178-742-9658
Mailing Address - Fax:
Practice Address - Street 1:539 W COMMERCE ST STE 5507
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-1953
Practice Address - Country:US
Practice Address - Phone:817-874-2965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty