Healthcare Provider Details

I. General information

NPI: 1093325243
Provider Name (Legal Business Name): REVAMED CENTER FOR EMOTIONAL WELLBEING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 W PALMETTO PARK RD STE 201
BOCA RATON FL
33433-3430
US

IV. Provider business mailing address

8140 OKEECHOBEE BLVD STE A&B
WEST PALM BEACH FL
33411-2003
US

V. Phone/Fax

Practice location:
  • Phone: 561-391-2770
  • Fax: 561-391-2930
Mailing address:
  • Phone: 561-293-4301
  • Fax: 561-293-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA STIELER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 561-432-2164