Provider Demographics
NPI:1801366554
Name:DIVINE HOLISTIC INTERVENTION SERVICES LLC.
Entity Type:Organization
Organization Name:DIVINE HOLISTIC INTERVENTION SERVICES LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRIETTA
Authorized Official - Middle Name:NGOZI
Authorized Official - Last Name:EVBUOMWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS LPC
Authorized Official - Phone:405-821-8646
Mailing Address - Street 1:1330 N CLASSEN BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-6834
Mailing Address - Country:US
Mailing Address - Phone:405-821-8646
Mailing Address - Fax:
Practice Address - Street 1:1330 N CLASSEN BLVD STE 310
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-6834
Practice Address - Country:US
Practice Address - Phone:405-821-8646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)