Healthcare Provider Details

I. General information

NPI: 1942929633
Provider Name (Legal Business Name): EVOLVING MIND PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W POLK AVE UNIT B
AUBURNDALE FL
33823-3428
US

IV. Provider business mailing address

4268 STAFFORD DR
WINTER HAVEN FL
33880-1141
US

V. Phone/Fax

Practice location:
  • Phone: 863-797-6544
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JASON FLOYD
Title or Position: OWNER/PROVIDER
Credential:
Phone: 863-797-6544