MEDICARE: MIND REVIVAL PSYCH INC

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	:	1043182280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND REVIVAL PSYCH INC

Provider Business Mailing Address
First Line	:	7201 S STONY ISLAND AVE # 7
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-2806
Country	:	US
Telephone Number	:	773-690-5300
Fax Number	:	870-201-4835

Provider Business Practice Location Address
First Line	:	7201 S STONY ISLAND AVE # 7
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-2806
Country	:	US
Telephone Number	:	773-690-5300
Fax Number	:	870-201-4835

Authorized Official
Title or Position	:	NP/OWNER
Name	:	MRS. EBONIE WILLIAMS
Credential	:	NP
Telephone Number	:	708-715-2035

Provider Enumeration Date	:	09/18/2025
Last Update Date	:	12/12/2025

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